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Neglected Tropical Diseases
An Integrated Plan of Action
Ministry of Health Indonesia 2011-2015
World He latnh
An Integrated Plan of Action to successfully achieve elimination and sustained control of 5 of the mostimportant neglected tropical diseases in Indonesia: Lymphatic Filariasis, Schistosomiasis,Leprosy,
World He latnh
Yaws and Soil-Transmitted Helminths.
Neglected Tropical
NEGLECTED TROPICAL DISEASES
Diseases in Indone
IN INDONESIA
An Integrated Plan of Action
An Integrated Plan of Action
Ministry of Health Indonesia
Ministry of Health Indonesia
2011-20152011 - 2015World He latnh
An Integrated Plan of Action to successfully achieve elimination and sustained control of 5 of the most important neglected tropical diseases in Indonesia: Lymphatic Filariasis, Schistosomiasis, Leprosy, Yaws and Soil-Transmitted Helminths.
Foreword by WHO Representative
Foreword by Director General Disease Control & Environmental Health
Executive Summary
Neglected diseases in Indonesia
Plan of Action for NTD control/elimination
General objectives
Country Profile
Geography and demographics
Political situation and administrative structure
Health care system
School Health Programme (UKS)
School Immunization Month Programme (BIAS)
Background of NTDs & disease control initiatives in Indonesia
Lymphatic filariasis
Soil-transmitted Helminths
Overlapping of NTDs endemicity
Health, hygiene & nutrition promotion
Integrated vector management
Integration between disease control initiatives
Drug supply and logistics
Development of Plan of ActionPlan of Action for NTD ControlGeneral objectivesExpected results
ER I Updated strategies based on international guidelines and best practices 43
ER II Accurate estimation of the burden of the 5 NTDs
ER III Successful management of drug donations
ER IV Strengthened capacity of health workers and volunteers
ER V Integrated social mobilization
ER VI Integrated and improved MDA for LF, schistosomiasis, and STH
ER VII Integrated and intensified morbidity case detection
ER VIII Integrated and intensified case management
ER IX Strengthened monitoring and evaluation (M&E) system for the 5 NTDs 50ER X Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws after their elimination as public-health problems
ER XI Establishment of a national NTD Taskforce
ER XII Increased visibility, advocacy and political commitment for NTD control and elimination
ER XIII Increased advocacy for comprehensive NTD control linking water, sanitation, hygiene education and chemotherapy
ER XIV Integrated health promotion
Milestones
A. Accelleration Program of Filariasis Elimination, Drug Availability and
B. Program Management, Advocacy, Socialization and Surveil ance (MONEV) 57
A. Detailed activities & Times
AusAID - Australian Agency for International DevelopmentDC & EH - Disease Control & Environmental HealthDEC
- Diethylcarbamazine
- Directorate General
- Department of Education
- District (or city) Health Office
- GlaxoSmithKline
- Information, Education and Communication
- Lymphatic Filariasis
- Multi-bacillary
- Mass Drug Administration
- Millennium Development Goals
- Monitoring and Evaluation
- Ministry of Health
- Neglected Tropical Diseases
- Primary Health Centre
- Provincial Health Office
- Serious adverse events
- School Health Programme
- Soil-transmitted Helminthiasis
UNICEF - United Nations Children Education FundUSAID
- United States Agency for International Development
- World Food Program
- World Health Organization
Health is recognized as an essential component of human development. In
collaboration with Ministry of Health, World Health Organization and other
development partners created several opportunities for improving the health
of people, enhancing quality of life and ensuring a better future. In spite of
various constraints, tangible progress has been made by governments, communities and
partners towards improved health outcomes; nevertheless, many challenges lie ahead.
These includes, weak health system, an increasing burden of communicable and non-
communicable diseases, high child and maternal mortality, recurrent epidemics and
humanitarian crises aggravated by disaster and limited financial resources. In accordance
with WHO's mandate, vision and collaboration and coordination with other partners, we
have pledged to continue to focus on partners role in the provision of normative and policy
guidance; strengthening of partnerships and harmonization of support to the country,
supporting health systems strengthening based on the primary health care approach;
putting neglected tropical disease at top of the agenda and intensifying the prevention
and control of communicable and non-communicable diseases; and accelerating response
to the determinants of health.
Indonesia is endemic for neglected tropical diseases (NTDs) for which chemotherapy
is available: lymphatic filariasis, soil-transmitted helminthes and schistosomiasis, leprosy
and yaws are among the major. Different studies have indicated that there are a number
of provinces and districts, where these diseases are co-endemic. Control programs for
these diseases are managed vertically and the potential benefits of integration of the
programs have not been explored. The country is uniquely positioned to make major
advances to reduce, and in some cases eliminate NTDs as public health problems given
the demonstrated commitment and strong programmatic experience of the government,
and a number of development partners working in NTD control. The NTDs form group
diseases are strongly associated with poverty, and these disease agents thrive best in
tropical areas, where they have very favorable conditions for the breeding and further
development. These diseases are largely silent, as the people affected or at risk have little
recognition in the communities and rarely have any political voice.
At present, the neglected tropical diseases have their breeding grounds in the places
left furthest behind by socioeconomic progress, where substandard housing, lack of access
to safe drinking water and poor sanitation, filthy environments, and abundant insects
and other vectors contribute to efficient transmission of infection for these diseases.
Close companions of poverty, these diseases also anchor large populations in poverty.
In developing countries like Indonesia the leprosy and lymphatic filariasis deform in ways
that hinder economic productivity and cancel out chances for a normal social life. The
infectivity of soil transmitted helminthic infection disrupts school attendance, contributes
to malnutrition and impairs the cognitive development of children.
The consequences are costly for societies and for health care such as rehabilitation for
leprosy and lymphatic filariasis. Fortunately, in the country these problems are now much
better documented and much more widely recognized. Good medicines are available for
many of these diseases, and research continues to document their safety and efficacy when
administered individually or in combination. Generous drug donations by pharmaceutical
companies have helped relieve some of the financial barriers and allowed programmes to
scale up coverage. A strategy of preventive chemotherapy, which mimics the advantages
of childhood immunization, is being used to protect entire at-risk populations and reduce
the reservoir of infection. The fact that many of these diseases overlap geographically has
practical advantages preventive chemotherapy regimens are being integrated so that several
diseases can be tackled together, thus streamlining operational demands and cutting costs.
An integrated approach to vector management likewise maximizes the use of resources
and tools for controlling vector-borne diseases are practical and feasible.
While the report highlights a number of remaining challenges, the overall message is
overwhelmingly positive. It is entirely possible to control neglected tropical diseases. Aiming
at their complete control and even elimination is fully justified, and this integrated action
plan sets out the solid evidence needed to achieve control.
Even though each Disease Control Sub-directorate at the MOH DG CDC & EH has
its own plan including some level of integrated activities for different diseases, this Plan of
Action was needed in light of recent announcement of enhanced drug donations for NTD
by pharmaceutical companies globally, renewed donor interest in funding NTD activities
for accelerating elimination and control, review and evaluation of schistosomiasis program
in Central Sulawesi (October-November 2010), finalization of LF plan for 2010-2014 (May
2010), and need to revitalize MOH integrated disease control strategy developed in 2007
that integrates some activities in the LF, leprosy, yaws and STH program.
This single document with key activities about a number of NTD in Indonesia is illuminate
synergies between NTD programs that enhance cost-effectiveness. This document can
help refine activities for accelerated control of NTD in light of recent international and
national developments and could be used as a tool to promote funding at national level
in the country and external funding for activities implementation. I would like to express
my sincere thanks to the Joint Mission Members from World Health Organization, USAID,
and AusAID for the technical support and helping in the process of the development of
integrated action plan on neglected tropical diseases to promote NTD Control in the
Republic of Indonesia
Khanchit Limpakarnjanarat
WHO Representative
The neglected tropical diseases (NTDs) are a group of infectious diseases which
primarily affect the poorest sectors of society, especially the rural poor and the
most disadvantaged urban populations. More than 1 billion people are affected with
one or more neglected tropical diseases, yet these diseases remain neglected at
all levels. Although some of NTDs affect Indonesia, over the past five years three of them
in particular – leprosy, lymphatic filariasis, and yaws – have been targeted for elimination.
These diseases not only affecting large number of population also carry high mortality and
morbidity; they also affect people's productive and social lives. Moreover, most of them
are feared and are the source of strong social stigma and prejudice and as a result, these
diseases are often hidden- out of sight, poorly documented and unmentioned.
Strategic steps taken by the international community have contributed to such progress:
the World Health Assembly passed resolutions for the global elimination of leprosy and
lymphatic filariasis in 1991 and 1997, respectively. In 2006, the WHO South-East Asia
Regional Committee passed a resolution calling all Member States to intensify efforts
towards achieving the goals of eliminating selected NTDs including yaws.
The Ministry of Health has targeted to decrease the diseases transmission, to prevent
diseases related disability, especially for leprosy and lymphatic filariasis and to diminish the
social stigma toward the diseases. Early case detection and early treatment with MDT (Multi
Drug Therapy) are the important strategy to be carried out to reduce leprosy burden.
Yaws elimination programme has been started out in hyper-endemic provinces and has
completed active case finding and treatment with benzathin penicillin, while the elimination
strategy for lymphatic filariasis relies on the mass administration of diethylcarbamazine and
albendazole to all individuals living in endemic areas.
Minimizing public stigmatization on leprosy and lymphatic filariasis patients are also
an important role to be conducted. We should push for integrating these programmes
with other sectors by implementing this developed integrated national action plan. We
should act rightly and promptly, working in teams which have high integrity, transparent
and accountable. NTD control requires an integrated approach with chemotherapy being
backed up by a range of supplementary interventions, along with inter-sectoral cooperation
by Ministry of Health, education, agriculture and other development related ministries.
I would like to make it clear that to make people healthy, there are four main strategies
that should become the guideline of every health worker, as follow:
1. Mobilize and empower people to live clean and healthy2. Improve the accessibility of people to the qualified health services3. Improve the surveillance system, monitoring, and information of health4. To ensure implementation of the activities outlined in this integrated plan of action,
additional funding need to be allocated from the government of Indonesia at central,
and district levels, as well as external funds from international donors.
Prof. dr. Tjandra Yoga Aditama
Director General DC and EH
WHO/USAID/AusAID Joint Mission for the Promotion of NTD Control in the Republic of Indonesia15-19 November, 2010Aim of the mission is to promote the development of a National PoA for the integrated control of NTD.International ParticipantsA Montresor, Scientist, Control of Neglected Tropical Diseases, World Health Organization,
Geneva, SwitzerlandM. Brady, Advisor, Control of Neglected Tropical Diseases, World Health Organization,
Geneva, SwitzerlandM. Pacque, GHFP Technical Advisor, USAID/Washington DCM. Linehan, Infectious Diseases Team Leader, USAID IndonesiaK. Kopoc, Director or CWW (Children without Worms)M Rebollo, Consultant, World Health Organization, Geneva, Switzerland
Ministry of Health IndonesiaTjandra Yoga Aditama, Director General of DC & EH Rita Kusriastuti, Director of Vector Borne Disease ControlH. Mohammad Subuh, MPPM, Director Direct Transmitted DiseasesTrihono, Director General National Institute of Health Research & DevelopmentSaktiyono, Programme Manager. LF, Schistosomiasis and STHChristina Widaningrum, Programme Manager, Leprosy and Yaws Taniawati Supali - Indonesia University World Health Organization: Regional Office A.P. Dash, Regional Advisor for NTD, WHO/SEARO, IndiaWorld Health Organization: Country Office Khanchit Limpakarnjanarat, WHO Representative, IndonesiaAnand B. Joshi, Program Manager for NTD, WHO- IndonesiaUSAID IndonesiaIrene Koek, Director, Office of HealthKendra Chittenden, Senior Infection Disease AdvisorArtha Camelia, Emerging Infections Diseases Specialist
Gerard Cheong, First Secretary Health Australian EmbassyGina Samaan, Consultant AusAID, Jakarta
JICA – IndonesiaYurico Egami WHO Indonesia - Neglected Tropical Diseas Working Group
• Khanchit Limpakarnjanarat, WHO Representative - Advisor and overall guidance
• M.R Kanaga, Administration/Management
• Anand B Joshi, Member: NTD focal point
• Graham Tallis, Member: Communicable Diseases Expert
• Sharad P. Adhikary, Member: Environmental Health Expert
• M Sudomo, Member: Schistososomiasis and LF expert
• Benyamin Sihombing:, Member: Leprosy, Yaws and other NTD specialist
• Nursila Dewi, Member: Information/ Communication
• Representative from USAID, Indonesia
• Representative from AUSAID - Indonesia
• Representative from JICA - Indonesia
Executive Summary
The Government of Indonesia has demonstrated awareness of the important
burden of neglected tropical diseases (NTDs). National plans and policies have been developed to fight leprosy, lymphatic filariasis (LF), schistosomiasis, soil-transmitted helminths (STH) and yaws. Successful experiences have demonstrated
the political commitment both at the central and district levels. Community compliance and participation are an important part of the NTD programs, as shown by the example of LF, where mass drug administration (MDA) is carried out with help of community volunteers or school deworming where children receive the drug during immunization days, achieving coverage of almost 90% of school-age children (SAC) in the areas where the program is implemented. However Indonesia faces many challenges to achieve the goal of control of STH and elimination of leprosy, LF, schistosomiasis, and yaws. Lack of coordination between different programs and stakeholders, insufficient and irregular political commitment at the district level, and limited funding to fully implement strategies and achieve sufficient coverage, makes it difficult for Indonesia to succeed in achieving the targets set by WHO for sustainable control and elimination of NTDs.
This Integrated Plan of Action (PoA) confronts many of those obstacles and proposes a
roadmap for integrated control of 5 of the main NTDs in Indonesia: leprosy, LF, schistosomiasis, STH and yaws. Under the leadership of a national NTD Taskforce, integration will focus on advocacy and social mobilization, use of a common pathway to distribute drugs and detect disease cases, capacity building of health workers, and health promotion at community level. This integrated NTD Program will facilitate cost savings and optimal use of human resources, as well as speed up implementation to find the shortest route to achieve the goals on time.
To ensure implementation of the activities outlined in this PoA, additional funding will
need to be allocated from Indonesian government at central and district levels, as well as external funds from international donors. Drug donations will continue to play a key role in the success of the plan. Neglected diseases in Indonesia
Neglected tropical diseases (NTDs) blight the lives of a billion people worldwide
and threaten the health of millions more. These ancient companions of poverty weaken impoverished populations, frustrate the achievement of health in the Millennium Development Goals and impede global development outcomes1.
Indonesia has one of the heaviest burdens of NTDs globally, with one of the largest
populations at risk. The country is endemic for five of the NTDs for which chemotherapy is available: leprosy, LF, schistosomiasis, STH, and yaws.
1 Working to overcome the global impact of neglected tropical diseases. WHO 2010
In 2000, Indonesia eliminated leprosy at the national level, with a prevalence rate of
less than 1 case per 10,000 populations. However, the number of new leprosy cases, approximately 20,000 per year, has remained stable for ten years. In 2009, 14 provinces and 160 districts, mostly in the east and central and west Java, still reported a prevalence rate of >1 per 10,000 population. Epidemic indicators such as the proportion of grade-2 disability (10.5%), the proportion of child cases (12.01%) and the proportion of multi-bacillary (MB) cases (82.43%) indicate that ongoing support is needed to reduce the leprosy burden.
The leprosy program aims to reduce disability from 10% to 5% by 2015, through rapid
index-case finding in high endemic areas. The National Programme for Leprosy's strategy consists of four main activities i.e., case finding, case detection, case management and mitigation of the impact of leprosy. Comprehensive case finding and detection efforts are important initial activities to identify and detect cases in a leprosy service area unit. Case management emphasizes accurate diagnosis and treatment. Counseling is an integral activity in case management to ensure treatment compliance and to overcome stigma. Mitigation of the impact of leprosy includes improving the quality of life of for people affected by leprosy through disability care and rehabilitation and psychosocial and economic support. The leprosy program estimates a cost of $60,000 per district for active case finding, for a total of $3 million for 50 districts. The Novartis Foundation supplies free drugs through WHO. The Netherlands Leprosy Relief and Sasakawa Foundation provide operational and technical assistance to the MOH program.Lymphatic Filariasis (LF)
LF is one of the major public health problems in Indonesia. All three types of lymphatic
parasites namely Wuchereria bancrofti, Brugia malayi and Brugia timori are prevalent in Indonesia, but B. malayi is the most dominant. Twenty-three species of mosquitoes are vectors for LF in Indonesia as of 2009, an estimated 125 million people are at risk of filariasis infection, in 337 endemic districts, which function as the LF program's implementation units. The highest prevalence rates were in Maluku, Papua, West Irian Jaya, East Nusa Tenggara and North Maluku provinces (all in east Indonesia). A total of 11,914 chronic cases have been reported nationally between 2000 and 2009.
The Government of Indonesia has decreed filariasis elimination as one of national
priorities to combat communicable diseases in line with Presidential decree number 7, 2005, and agreed to participate in the international goal launched by WHO to eliminate LF as a public health problem by 2020. The LF program's objectives are to reduce and eliminate transmission of LF by MDA, and to reduce and prevent morbidity in affected persons. In 2009, MDA with diethylcarbamazine (DEC) + albendazole covered more than 19 million people in 30% of the endemic districts, with an average program drug coverage rate of 66.5% of the at-risk population in those districts. Albendazole is donated by GlaxoSmithKline (GSK) through WHO and DEC is purchased locally. According to the 2011-2014 National Plan for LF, the central government is responsible to ensure the procurement of drugs and provide
routine budget, while the local government is expected to contribute the operational and maintenance budget. External funding is required to achieve the goal of elimination by 2020. The cost of distribution per person calculated in the National Plan is US $0.23.
Schistosomiasis, due to Schistosoma japonicum, is endemic in the Lindu, Napu and Bada
valleys in Central Sulawasi province, with an at-risk population of 25,000 to 50,000. Although control activities ended in 2005, 2010 surveys showed a resurgence of transmission with an average prevalence of infection of 9.6% among 5 villages in Napu Valley. These areas have restricted access to potable water and sanitation, with few families having latrines. The program has limited resources for control operations and praziquantel for treatment of those infected has not been readily available. A detailed and budgeted plan (2011-2014) for schistosomiasis elimination was developed by the Vector-Borne Disease Control Directorate (VBDCD) within MOH. The total cost of the programme in the draft plan is US $4,838,760 for the period. The unfunded gap is equivalent to 65% of the total amount.
Soil-transmitted helminths (STH)
In the last 15 years, hundreds of districts have been surveyed in Indonesia to assess the
STH prevalence. Over 40,000 individuals (mostly children) were involved. Results show that STH infection is widespread in the country and, according to WHO guidelines, most of the areas surveyed need at least one treatment/year. Preliminary predictive mapping for areas for which data are not available suggests that STH are intensively transmitted through the entire country.
In 2009, more than 19 million individuals were treated with donated albendazole through
LF MDA; this treatment resulted in deworming of 1 million preschool children and 3.6 million school-age children. An additional number of children were dewormed through the school system by local authorities and international partners such as the World Food Programme (WFP); however exact treatment figures are not known at national level. Twenty-one and a half million children live in districts where LF is not endemic and therefore do not benefit from the impact of albendazole distribution through LF MDA. As some of these districts are highly endemic for STH, they would benefit from a donation of mebendazole.
Currently 18 of the 33 provinces are believed to be affected with yaws, with five classified
as high burden. In 2009, 8,309 cases were reported (mostly from 6 districts in Nusa Tenggara Timur province), and numbers have been increasing steadily since 2001 (when 2,112 cases were reported). From the remaining provinces, no information is available. The MOH strategy is designed to eradicate the disease by 2013. The strategy includes active case-finding of cases and their contacts, mobilization of community support, capacity building of health staff for detection and management of cases, and establishment of partnerships with other disease control programs and external partners. Active case finding, or annual ‘search and treat' missions, is planned to scale up from 10 districts in 2010 to 18 districts in 2011, using an island-by-island approach. Technical assistance, monitoring, supervision and
2 WHO. Preventive chemotherapy in human helminthiasis. Geneva, World Health Organization, 2006.
training are integrated with the leprosy programme. The program estimates a budget of $80,000 per district, not including technical assistance and monitoring, for a total cost of $9 million over 5 years. Plan of Action for NTD control/elimination
The Government of Indonesia is committed to intensify its efforts to control and
eliminate five of the most important NTDs affecting the country and causing suffering and impoverishing millions of people. This Plan of Action (PoA) was developed to improve the management of each disease and make the programs more efficient by integrating some of the activities in a way that will save human resources, time and money. This integrated approach should obtain better health results and help achieve the final goal of sustained control of STH and elimination of leprosy, LF, schistosomiasis, and yaws from Indonesia.
to strengthen the Indonesian health system through improved training, advocacy and coordination at all levels of the health system,
ii) to strengthen multi-sectoral collaboration within the MOH, Ministry of Education,
Ministry of Internal Affairs and Ministry of Religious Affairs among others, and
iii) to strengthen the national capacity for successful management of international
cooperation funding (USAID, AusAID, WHO and other international agencies) and drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel, leprosy multidrug combination).
The main expected results of this PoA are:
Updated strategies based on international guidelines and best practices
ii) Accurate estimates of the burden of these 5 NTDs to improve macro and
micro planning, monitoring and evaluation.
iii) Successful management of drug donations. Lack of timely access to drugs
constitutes a barrier for success of most of the programs. However, there are companies willing to donate their drugs to countries which can demonstrate their capacity to forecast and distribute the drugs to those in need.
iv) Strengthened capacity of health workers and volunteers through integrated
training at all levels. Activities which strengthen the knowledge, abilities, skills and behavior of individuals (MoH, health workers, school teachers and communities) and improve institutional structures and processes help the program more efficiently meet its mission and goals in a sustainable way.
v) Integrated social mobilization activities, key for the success and sustainability
vi) Integrated and improved MDA for LF, schistosomiasis, and STH including
scaling up and increasing coverage to achieve the individual program goals.
vii) Integrated and intensified morbidity case detection for leprosy, LF and
yaws through MDA campaigns and field visits of health care workers (index case contacts study). Intensified case-finding during LF MDA campaigns and IEC activities is a unique opportunity for leprosy and yaws elimination efforts to screen communities.
viii) Integrated and intensified case management for leprosy, LF and yaws
through field visits of health workers and support to self-care groups. Improving case management is one of the best ways to fight stigma and discrimination of chronic patients, win the trust of the community, and increase self declaration by suspected patients.
ix) Strengthened monitoring and evaluation system for the 5 NTDs. x) Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws
after the elimination of these diseases as public health problems.
‘Supporting' expected results are:xi) Establishment of a national NTD Taskforce. By joining all national and international
stakeholders in a single network, the program will improve coordination among the different programs, integrate of activities, share results, facilitate solutions, and maximize impact.
xii) Increased visibility, advocacy and political commitment for NTD control
and elimination. Having one PoA for 5 different NTDs will increase their visibility and will facilitate political and financial commitment by maximizing results with minimum cost.
xiii) Increased advocacy for comprehensive NTD control which links water,
sanitation, hygiene education and chemotherapy. A long-term solution to fight and eliminate diseases related to poverty is to fight poverty itself, by improving living conditions and enabling people to change their behavior by having access to water, sanitation and hygiene education.
xiv) Integrated health promotion and hygiene education. Every opportunity will
be used to promote health and hygiene in the community. Social mobilization campaigns, MDA, school deworming days, self-care groups as well as every contact with the health system will be use to promote hygiene and health habits.

an integrated actions
Social mobilization
Summary budget

Integrated Neglected Tropical Disease Budget Estimation in USD Estimated Operational Estimated Operational Estimated Operational Estimated Operational Operational government government government government commitment (External commitment (External commitment (External commitment (External Estimated (External government required) required) required) required) commitment required)
Lymphatic filariasis
Soil Transmitted
Helminthic Infection (STH)
Leprosy and Yaws
Grand Total 11,650,000 6,000,000 11,650,000 6,000,000 11,650,000 6,000,000 11,650,000 6,000,000 11,650,000 6,000,000 perational (External required) perational (External required) et Estimation in USD perational (External required) Tropical Disease Budgopical Diperational (External required) Integrated Neglected perational (External required) escription phatic filariasis inthic Infection Soil Transm Geography and Demographics
Indonesia is the largest archipelago country in the world with 17,508 islands of which
6,000 are inhabited3 . It is located in Southeast Asia between the Indian Ocean and
the Pacific Ocean, and spans a total area of 1,919,440 sq km (land 1,826,440 sq km &
water 93,000 sq km). Indonesia has a number of natural resources including petroleum,
tin, natural gas, nickel, timber, bauxite, copper, fertile soils, coal, gold, silver. Various islands
periodically face natural disasters such as floods, severe droughts, tsunamis, earthquakes,
volcanoes and forest fires4.
In 2008, the population was estimated at 228.8 million, of which 168.3 million are ≥15
years old. The gross income per capita was estimated at USD 3,310 (Box 1). The major
religion in Indonesia is Islam with 88% of the population, followed by Protestant 5%, Roman
Catholic 3%, Hindu 2%, Buddhist 1%, other 1% (1998 data)4. Infant mortality rate (IMR)
nationally is 26.8, ranging from 8.2 in DKI Jakarta province to 43.2 in West Nusa Tenggara
Box 1: Demographic statistics in Indonesia5
Total population: 228,864,000Gross national income per capita (PPP international $): 3,310Life expectancy at birth m/f (years): 66/69Healthy life expectancy at birth m/f (years, 2003): 57/59Probability of dying under five (per 1 000 live births): 34Probability of dying between 15 and 60 years m/f (per 1 000 population): 231/192Total expenditure on health per capita (Intl $, 2006): 87Total expenditure on health as % of GDP (2006): 2.2
Based on Bureau of Statistics 2008 data,3 mean years of schooling is higher for males than
females (8 years vs. 7.1 years) nationally. The National Socio-economic Survey (SUSENAS),
a household survey conducted by the Indonesia Bureau of Statistics (BPS), found that 96.1%
of children 7-12 years old were enrolled in school, compared to 79.2% for children 13-15
years old, and 49.8% for children 16-18 years old. School enrollment varies from 99.52% in
Jogjakarta province to 83.38% in Papua province.
The percentage of households using an improved drinking water source, such as a pump/
well/spring water (that are at least 10m away from a septic tank), was 52.72% nationally. This
varied widely from 69.21% in Jogjakarta province to 34.86% in West Papua. Importantly, the
regional variation did not necessary correlate with urbanization since city provinces such
as Jakarta also had low rates (44.33%).
3 Bureau of Statistics: www.dds.bps.go.id/eng/download_file/booklet_leaflet/booklet_okt2009.pdf4 Asian Center for the Progress of Peoples 2007: www.acpp.org/uappeals/cprofile/Indo%20Country%20Profile.pdf 5 World Health Statistics: http://www.who.int/healthinfo/statistics/en/
Political situation and administrative structure
Indonesia is a democratic republic with 33 provinces encompassing 397 districts and 98
cities3. Indonesia's governance was decentralized to the level of district/city on 1 January
2001. The 495 districts and cities have become the key administrative units responsible for
providing most government services including health but excluding defense and national
security, foreign affairs, fiscal policy and religion. Since 2001 the situation has evolved and
currently decentralization in Indonesia has entered a new phase of consolidation; however
local institutions in many districts and cities still lack the capacity to fulfill their new mandates
effectively. Further, development indices, poverty rates, and proneness to crisis (conflict or
natural disasters) vary across different provinces. Coupled with the diversity in culture,
terrain and population, these have made implementation of interventions a challenging
task6 . The Ministry of Interior Affairs (Dalam Negeri) is the key ministry responsible for
decentralization and the funding of regional governments.
Health care system
The overall health financing situation in Indonesia is complex and incompletely
documented7. In 2003, around 34% of total health expenditure was undertaken by public
sector agencies, while 66% was private. By far the largest single source of private expenditure
was direct out-of-pocket payments by households, accounting for nearly half of the total
expenditure. Insurance coverage has been increasing since the advent of the new social
insurance scheme for the poor7.
The general decentralization process implemented in 2001 has had many impacts on
the health system, even though it was not designed specifically with the health sector
in mind. In particular, health financing, health information system, human resources for
health and service provision have been affected. Under decentralization, responsibility
for health care provision is largely in the hands of district/city governments. Despite
this, the central government continues to set the national agenda, targets for health and
along with the provincial governments, provides a supervisory, support and monitoring
role for district/city governments.
The Ministry of Health (MOH) in Indonesia, situated in the capital Jakarta, has 4
Directorate-Generals, 2 Institutes, an Inspectorate-General and a Secretariat-General
under which there are 14 Centers and Bureaus (Figure 1). A number of these structures are
critical for the control of NTDS under consideration in this PoA. Primarily, the Directorate-
General of Disease Control & Environmental Health (DG DC & EH) has five directorates,
where the Directorate of Vector-Borne Disease Control oversees LF, schistosomiasis & STH
control and the Directorate of Directly-Transmitted Diseases oversees leprosy and yaws
control. Under the DG DC & EH, there is a planning unit, finance unit and a regulation unit that are involved in the overall management of the business of the Directorate-General.
6 Government of Indonesia and UNDP Country Programme Action Plan, 2006-10 www.undp.or.id/pubs/docs/CPAP%202006-2010.pdf
7 World Health Organization Indonesia Country Office www.searo.who.int/indonesia
Figure 1: Organizational structure of Ministry of Health, Indonesia*STRUKTUR ORGANISASI DEPARTEMEN KESEHATANSTAF AHLI MENTERIKEUANGAN DANHUKUM DANDAN ANGGARANBINA KEFARMASIAN DAN ALATPENYAKIT DAN PENYEHATANPEMBERDAYAAN SDM KESEHATANPUSAT PEMELIHARAAN PENINGKATAN, DAN DATA SURVEILANS PEMBIAYAAN DAN KOMUNIKASI SARANA, PRASARANA DAN KERJASAMA LUAR
*Menteri kesehatan = Minister of Health, Direcktorat Jendral Pengendalian Penyakit dan Penyehatan lingkungan
= DG DC & EH, Direktorat Jendral Bina Kefarmasian dan Alat Kesehatan = DG Pharmacy and Health
Supplies, Pusat Promosi Kesehatan = Centre for Health Promotion, Pusat Kerja Sama Luar Negeri = Centre for International Collaboration, Direktorat Jendral Bina Pelayanan Medik = DG General Medical Services,
Direktorat Jendral Bina Kesehatan Masyarakat = DG Community Health.
For NTD control, the DG DC & EH also coordinates with the Centre for Health
Promotion, the Bureau of Planning & Budgeting (under the Secretary-General), as well as
the Directorate-General for Pharmacy & Medical Services and the National Institute for
Health Research & Development. In addition to lateral coordination, the DG DC & EH
also coordinates with the provincial and district health authorities. Structures for disease
control such as vector-borne diseases and directly-transmitted diseases are replicated on a
smaller scale in provincial governments. The general division of mandate between national,
provincial and district/city governments can be seen below:
• Central MOH: prepare national strategy, guidelines & regulations for disease control
and provide a supervision, monitoring and support role to provincial and district/city
• Provincial Health Office (PHO): adopt national strategies to develop provincial
strategy based on local situation, provide training, funding support, supervision &
monitoring for district/city level health offices
• District/City Health Office (DHO): develop district/city level plans, directly implement
disease control activities, supervise lower health structures such as primary health
School Health Programme (UKS)
There are about 175,000 public, religious and private schools in Indonesia, all of which are
eligible to participate in the School Health Programme (UKS - Upaya Kesehatan Sekolah).
There are about 27 million students in primary school, about one quarter of whom are
in religious schools (Madrasah Ibtidaiyah). Education is compulsory and provided free of
charge in public schools for children from 7 to 15/16 years of age, corresponding to all
6 classes of primary school and 3 classes of secondary school. The number of teachers
working in primary schools is 1.38 million.
The three major UKS programmes include health education, health service delivery
through schools, and a healthy school environment. In addition to immunization, the health
services delivered include health and nutrition screening for new students; height and weight
monitoring; health education, dental care; iron and iodine supplementation; and de-worming
in some areas. Booklets and materials have been developed for UKS, which provide the
objectives of the program, health information, how to conduct health promotion in schools
and monitoring/evaluation procedures. Content includes information about good nutrition
and how to build latrines and water pipes.
The MOH Child Health Directorate coordinates activities relevant to the UKS. Four
ministries (MOH, Ministry of Education, Ministry of Internal Affairs and Ministry of Religion)
are involved in UKS. The implementation is mandated by teachers and supported by primary
health care staff in all schools, including religious schools. There is also a ministerial decree
about minimum standards in schools for ensuring health (KepMenKes 1429/MENKES/SK/
XH/2006). School Immunization Month Programme (BIAS)
In 1998, the Ministries of Health, Education (MoE), Religious Affairs (MRA), and Internal
Affairs launched Bulan Imunisasi Anak Sekolah (BIAS), School Immunization Month
Programme. BIAS was designed to be a sustainable routine activity to eliminate tetanus and
provide diphtheria boosters. In 2000, measles campaigns for 6-12 year olds were included
in provinces that had funding. Since 2003, reported vaccination coverage in schools through
BIAS has been about 95% each year.
The MOH has the responsibility for policy, service delivery and evaluation, while the
MoE and MRA handle social mobilization. The Ministry of Internal Affairs, through its local
government and municipality offices, is responsible for covering operational costs. The
UKS team leader at each level coordinates and monitors implementation of the overall
integrated school health programme, including BIAS. Within the MOH, the staff in charge of
health promotion at each level looks after UKS overall; however, the Expanded Programme
on Immunization (EPI) is given responsibility at each level to implement BIAS. The UKS
guru(s) oversees BIAS within the school.
BIAS is managed, supplied and implemented without the technical or financial involvement
of multilateral or bilateral partner agencies. While BIAS was integrated within the existing
UKS structure, most respondents at lower levels indicated that the existence of the UKS
structure was helpful but not in fact required for the adoption of BIAS, since the health
workers felt they were able to forge good relations with local schools on their own.

Background of NTDs & disease control initiatives in Indonesia
Leprosy is a disease caused by Mycobacterium leprae, a bacterium which primarily af ects
the skin and peripheral
f NT main mode Ds & disea of se ctransmission ontrol initia is considertives in In ed sia air-borne,
through droplets discharged from the respiratory tract of untreated infectious cases, who form
<10% of the clinical
The disease is completely curable with multi-drug therapy (MDT)
and is considered
yc ectious
obacteriu m diseases,
leprae, a bwith
skin and peripheral nerves. The main mode of transmission is considered to be air-borne, through
having adequated i
can be victims of
the discrimination
clinical cases. The and
sease is c displacement.
ompletely curable This
MDT) disabilities
and deformities that occur as a consequence of peripheral ner
considered to be one of the least infectious diseases, with ov vere damage in lepr
99% of the populati osy
adequate immunity against the disease. The disease causes stigma and those affected can be victims of discrimination and often displacement. This is mainly due to the disabilities and
Epidemiologydeformities that occur as a consequence of peripheral nerve damage in leprosy.
chieved leprosy elimination (yearly prevalence rate <1 per 10,000)
at the national le
1 rpte ra 1p0,r0e0v0a) len
of >1 per 10,00n0
el aisn e2 0d0e0, te
14c toiuot no f rat
the e3 3 opf ro>vi1n0
10,000 and a case detection rate of >10 per 100,000 population. 2007 data from the MOH show from
460 districts. Furth
cati torn aotf ifi
heaviest diseasei n bur
stricts . ofFi gthe
cates the b . urden of disease by province in
Figure 2: Indicates the burden of disease by province in IndonesiaFigure 2: Leprosy burden in Indonesia as of 31 December 2009, by province

Leprosy Burden in Indonesia (31 Desember 2009)
Total number new cases 17,260 (Rate:7,49/100 000)
Population 2009 : 230.473.991North MalukuWest PapuaHigh burdenOr new case> 1000Low burdenDKI JakartaWestJava Central Java EastJava WestSulawes Si outh Sulawesi SE Sulawesi C. SulawesiCDR<10/100000 573 (6.33) 1.559(3.69)1574(5.08) 5923 (15.82) 195 (14.62) 1236(16.2) 249(11.62) 313 (12.93)Or new case <1000As per MOH Report
Since 2000, 17,000-18,000 new cases have been reported each year, of which 10% have grade-2 disability and of which 10% are children. More than 70% of the new cases are of the multi-
Since 2000, 17,000-18,000
grade-2 disability
the multi-bacillar
ases wi (MB).
ated cases wi risk
grade-2 disabilities thus increasing the burden of socio-economic rehabilitation on the national,
developing disabilities
for disease transmission. Each
year about 1,500 new cases with grade-2 disabilities are added to the pool of about 26,000
accumulated cases with grade-2 disabilities thus increasing the burden of socio-economic
rehabilitation on the national, local governments and communities (Figure 3).
e 3: igure 3: Leprosy disea Indicates the bur se trends in Indoneden of disease b sia, y pr 2o000-2008 vince in IndonesiaLeprosy Trend -Indonesia 2000-2008
In Jul y 2009, the MOH conducted a survey to assess the extent of under-detection. A
district ess the
(total extent of un
trained ct (total
village il ion) in
health vEast Java pro
rapidly screened by trained health workers, village health volunteers (cadres); people affected by
people affected by leprosy and community leaders. A total of 338 new leprosy cases were
leprosy and community leaders. A total of 338 new leprosy cases were identified (case detection
identified (case detection rate was 60 per 100,000 examined population), of which 262
rate was 60 per 100,000 examined population), of which 262 (78%) were of MB type. The MB
(78%) were of MB type. The MB case detection rate was 46 per 100,000 population. Forty-
case detection rate was 46 per 100,000 population. Forty-three (13%) new cases had grade-1
grade-1a de-2 disab
disability. i lity, of which
Sixty-one . 49 (1
e lyd rscale up public
ecommended awarene
eness g in highly e
omote early case finding in highly endemic areas.
Strategy and Activities
Strategy and Activities
The Sub-directorate for Leprosy and Yaws, in which the National Leprosy Control Programme is
Sub-dir as 12 staff
ectorate aft nati
National ne staff
of leprosy, more than one staff works on the program. Health center workers, other health care
staff member is trained and responsible for the leprosy program. In provinces and districts
workers, and health volunteers (cadres) also help implement the program's activities.
with heavy burdens of leprosy, more than one staff works on the program. Health center
workers, other health care workers, and health volunteers (cadres) also help implement
WHO recently published the enhanced Global Strategy for Further Reducing the Disease Burden
ogram'o Leprosy: Pl
s activities. an 2011-20158. This strategy sets a new global target to reduce the grade -2
disability rate per 100,000 population among new cases by 35% by 2015, compared to a 2011
WHO recently published the enhanced Global Strategy for Further Reducing the
baseline level. The strategy promotes the use of voluntary self-reporting for case detection,
Disease Burden due to Leprosy: Plan 2011-20158. This strategy sets a new global target
rather than large-scale campaigns since these have become less effective. Further, the strategy
100,000 these peopl
populatione are at g
compared to a 2011 baseline level. The strategy promotes the use of voluntary self-
case the global str
detection, ategy f
than 1-2015, the
large-scale Leprosy Prog
emphasizes communicatio
household n (IEC) acti
contact vities to prom
examination ote earl
finding in the high-burden districts to reduce grade-2 disability and to reduce disease
people are at greater risk of disease.
transmission, focusing on 10 districts per year. The activities in the broad plan include orientation
2011-2015,u nity
ormation, paigns and
unication onitori
omote early case finding in
high-burden districts to reduce grade-2 disability and to
disease d Global Strategy
transmission, ffor Further
(WHO, 2009). http://www.searo.who.int/LinkFiles/GLP_SEA-GLP-2009_3.pdf
plan include orientation of health workers, micro-level planning, community mobilization,
IEC material production, IEC campaigns, rapid case finding campaigns and supportive
8 Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy: Plan 2011-2015 (WHO, 2009).
supervision/monitoring. MOH has produced ample IEC material of excellent quality ready
for dissemination, which is also available in CD format so that local governments can
duplicate/print the standard materials.
The Leprosy Programme conducts 21-day annual training of province and district
leprosy workers at the National Leprosy Training in Makassar, South Sulawesi. Health center
workers take part in 5 day trainings, other health workers are trained for 1 day, and cadres
are trained for half a day. However, in sub-districts with intensified case finding with IEC
campaigns, the programme conducts an additional 1-day annual training that focuses on
the an overview of leprosy and yaws, a description of the local epidemiology, and how to
identify suspect cases. The morning session is for health care workers and cadres, as well
as other sectors (religious, social welfare, education and local government). The afternoon
session is for health center works only and focuses on more technical aspects of disease
recognition and treatment.
The Programme receives drug donations via WHO yearly for case management. The
drugs are imported into the country by WHO and are then distributed to district level
from MOH budget. The budget is reliable but has been delayed in previous years. The total
cost is approximately USD 66,000 to enable distribution of drugs four times per year
to district level, handling a total of 25 ton (25,000 kg). The cost per kilogram averages
Rp24,000 (2.65 USD). Further dissemination is the responsibility of the local government,
which is problematic since it relies on the assurance that the budget line is maintained by
the local level planning system.
Another aspect of the control program is the recent establishment of PerMaTa – groups
for people affected by leprosy. PerMaTa is now present in parts of East Java, South Sulawesi,
East Nusa Tenggara and Jakarta.
The Netherlands Leprosy Relief (NLR), an international non-governmental organization
(NGO), is supporting the MOH in leprosy case detection and disability management. NLR
has an office in Jakarta but also has staff in some of the high-burden provinces. Among the
activities conducted by NLR include monitoring and evaluation meetings in high-prevalence
districts which provide an opportunity to re-train field staff, and support to some of the 13
leprosy hospitals around the country including five hospitals for prosthesis.
In addition, the Sasakawa Foundation provides support to manage the disabilities
arising from leprosy. Further information regarding the Sasakawa support will be available
once the workplan is completed. The WHO also provides limited funds to the MOH for
leprosy control, which in the past have been used to fund case finding missions and national
meetings. Lymphatic filariasis
Lymphatic Filariasis (LF) is caused by helminthic worms inhabiting the lymphatics. The
disease predominantly afflicts poor people in both urban and rural areas as well as marginalized
and neglected populations. It is usually acquired in early childhood and is responsible for
considerable morbidity, causing social stigma among men, women and children. LF is one the
only six infectious diseases considered eradicable by WHO with the available tools9.
9 Lymphatic Filariasis: the disease and its treatment (WHO, 2006). www.searo.who.int/en/Section10/Section2096_10583.htm
LF is one of the major public health problems in Indonesia. All three types of lymphatic
parasites namely Wuchereria bancrofti, Brugia malayi and Brugia timori are prevalent in
Indonesia (Figure 4), but B. malayi is the most dominant. Twenty-three species of mosquitoes
are vectors for LF in Indonesia.
Figure 4: Distribution of filarial parasite in Indonesia
Since 2005, districts or cities have been used as the implementation unit (IU) to
determine endemicity and implement MDA. The MOH finished mapping endemicity
throughout the country in 2009, albeit some districts were mapped using epidemiological
surveys (proximity of district to endemic districts, presence of chronic cases and MF rates
surrounding chronic cases) rather than MF surveys using Lot Quality Assurance Sampling
(LQAS), as recommended for confirmation of endemicity in WHO guidelines.10
As of 2009, an estimated 125 million people are at risk of filariasis infection, in 337
endemic districts, i.e. where microfilaremia (MF) >1% (Figure 5). Based on blood surveys
for MF in Indonesia, province level prevalence varied from 0-38.57%. The highest rates were
in Maluku, Papua, West Irian Jaya, East Nusa Tenggara and North Maluku provinces (all in
east Indonesia). A total of 11,914 chronic cases have been reported nationally between
2000 and 2009, although this is most likely an underestimate given that it only includes
cases that sought care through the national health system.
10 WHO. Preparing and implementing a national plan to eliminate lymphatic filariasis (in areas where onchocerciasis is not co-endemic).
ure LF endemicity in Indonesia based on sur5: LF endemicity in Indonesia based on survev ys up to September 2009,eys up to September 2009, bb y districty district
Strategy y and
The LF Program sits within the Sub-directorate for Filariasis and Schistosomiasis. At
ari , schistosomiasis
asis and Schistoso and
omiasis an df or LF
STH. , schistosomiasis,
At provincial and and/or
the Head of Health, the Head of Division, the Chief of Section and functional staff are responsible
staff are responsible for communicable diseases. At primary health centre level, the Head
for communicable diseases. At primary health centre level, the Head of Health Centre and
of Health Centre and functional staff also are responsible for control of all communicable
functional staff also are responsible for control of all communicable diseases.
aigns, scalin gscaling
esource c oresour
districts ofte ndistricts
only partial coverage of the at-risk population within the district.
often provide only partial coverage of the at-risk population within the district.

Table 1. MDA coverage 2006-2009 MDA2 (DEC+ALB) Population Targeted 7,075,000 11,116,000 16,799,000 28,719,000 Population Treated 5,325,000 8,411,000 12,310,000 19,160,000
Geographical Coverage
Programme Coverage
National coverage
The LF Program conducts 5-days annual training of central and province LF workers
central management
ining management
ent prog conduct
vince level tray,
training management
of district LF of wLF
management program, treatment and case management of LF. In district level LF
annual training of health center that focuses on management program, treatment and case
training conduct 2 days annual training of health center that focuses on management
management. Whereas in health center level conduct one day training that focuses on the
program, treatment and case management. Whereas in health center level conduct one
d w of LF and mass tr
ay training that fo
cuses on the an overview of LF and mass treatment.
DEC for MDA campaigns is purchased locally and albendazole is donated by GSK
through WHO. The donated albendazole takes approximately two weeks to get cleared
by customs. The central program covers the cost of distribution from central to province
level; distribution is arranged by the Directorate General Pharmacy and Health Equipment
and takes approximately one month from Jakarta to the district level. Districts contribute
to the cost of distribution from the province level to the villages. The district health office
repackages the drugs and distributes to health centers; a process taking approximately two
The Sub-directorate developed a National Plan for the Acceleration of Filariasis
Elimination in Indonesia (2011-2014). The plan is expected to be sustained until 2020,
where the first 5 years of acceleration will be to scale up application of MDA campaigns
in all endemic districts. However, even though this is the target, the plan only outlines the
timetable for implementation of MDA for some endemic districts.
The main pillars of the National Plan are:
1. Transmission elimination through MDA in endemic districts once a year for at least
5 years covering at least 65% of the total population in the implementation unit.
2. Increasing coverage of clinical treatment of acute and chronic cases to 90% of
Currently, MDA has been scaled up in a geographically scattered way to address high
prevalence areas and political needs. The 2010-2014 plan does not include a justification
why certain districts were chosen for scaling up in certain years, beyond an emphasis on the
eastern part of the country. Ideally, this plan would be realigned so that contiguous districts
would scale up MDA at the same time, both for epidemiological and logistical reasons. If
the plan cannot be adjusted, it is recommended that donor support be used to fill in the
gaps to achieve geographical coherence.
Case management has been introduced in some provinces and districts, through hospital
care and self-support treatment. However, there is currently limited financial support for
training of health care staff or treatment of cases.
Donors, universities and NGOs have played a critical role in assessing disease burden,
supporting trainings and MDA campaigns. GTZ supported the University of Indonesia to
undertake operational research to implement MDA campaigns, including health promotion
aspects and M&E, in Alor Island, East Nusa Tenggara province. The district raised the budget
for operational aspects such as distribution of drug and monitoring of severe adverse
events (SAE). This study showed that the initial mapping undertaken underestimated the
prevalence of MF and that ongoing stakeholder negotiations with local government and
health staff training are required to achieve high MDA coverage.
Research in Indonesia has been critical to inform the national program but also provide
information to the global understanding and recommendations on LF control. A University
of Indonesia study concluded that the combination of albendazole and DEC is effective
for Brugian species, but takes more than five days to decrease MF for Bancroftian filariasis.
Further, the University of Indonesia, with support from the Bill & Melinda Gates Foundation,
is comparing the impact of twice-yearly MDA campaigns for three years versus once-yearly
MDA campaigns for five years.
Schistosomiasis in Indonesia is caused by a parasite, Schitosoma japonicum, which infects
a number of mammals, including humans. The intermediate host is Oncomelania hupensis
lindoensis, an amphibious snail. The snail lives in abandoned rice fields, along ditches, known
as "disturbed habitat", under dense wild canes, along creeks or seepage waters. In humans,
the disease has toxic and dysenteric symptoms as well as loss of appetite and weight,
emaciation, retarded growth, in young patients. Hepato-splenomegaly and ascities are
characteristic, progressing to death. Currently, single dose treatment with praziquantel is
the treatment of choice since it is highly effective, easy-to-administer, and with minimum
side effects. WHO provides donations of praziquantel to affected countries, however, global
supplies of the drug are limited.
In Indonesia, schistosomiasis is known to occur in three very isolated areas in two
districts in Central Sulawesi province: the Bada, Napu and Lindu Valleys (Figure 6). A
comprehensive control program was initiated in Lindu and Napu valleys in 1973. Control
strategies included chemotherapy, hygiene & sanitation improvements and agro-engineering.
However, due to diminishing funding after the termination of a specific control program
in 2005 and the absence of post-elimination campaign activities, infection rates started to
rise in 2006. By 2009, prevalence in the Napu valley reached 3.8%. In the same period, the
infection rate among snails increased from 0 to 13.4% and 0 to 9.09% in Napu and Lindu
Figure 6: Schistosomiasis endemicity in IndonesiaStrategy and Activities
The Schistosomiasis Program sits within the Sub-directorate for Filariasis and
Schistosomiasis. At central level, there are 11 staff members working on LF, schistosomiasis
and STH. At provincial and district health offices, there are no specific staff members for LF,
schistosomiasis, and/or STH. Instead the Head of Health, the Head of Division, the Chief of
Section and functional staff are responsible for communicable diseases. At primary health
centre level, the Head of Health Centre and functional staff also are responsible for control
of all communicable diseases.
Based on an Oct-Nov 2010 evaluation mission by WHO, a number of challenges were
identified for the disease control program. Since disease levels were brought to low levels in
previous years, there have been difficulties in sustaining policymakers' interest and allocation
of budgets for disease control activities. Further, there has been a lack of coordination
between the MOH and others departments involved in the environmental and agricultural
aspects of the overall strategy. Based on the evaluation mission, resumption of the control
program would be critical to eliminate the disease where the at-risk population is up to
50,000 people, with mapping done to clearly define if there are other endemic areas in
the highlands of Central Sulawesi. At the core of the strategy is yearly MDA to reduce
disease incidence in humans. This would slowly reduce environmental contamination and
thus snail infection, curbing the disease cycle over time. The core strategy of MDA can be
coupled with education to the local community, rat and snail surveillance, and support to
the environmental management programs including introduction of latrines and suitable
water sources. Soil-transmitted Helminths
Soil Transmitted Helminthiasis is the infection with one or more intestinal parasitic
worms: roundworms (Ascaris lumbricoides), whipworms (Trichuris trichiura), or hookworms
(Necator americanus and Ancylostoma duodenale). Infected people excrete helminth eggs
in their feces, which then contaminate the soil in areas with inadequate sanitation. Other
people can then be infected by ingesting eggs or larvae in contaminated food, or through
penetration of the skin by infective larvae in the soil (hookworms). Infestation can cause
morbidity and, in rare instances, death, by compromising nutritional status, affecting cognitive
processes, inducing tissue reactions, such as granuloma, and provoking intestinal obstruction
or rectal prolapse. Control of helminthiasis is based on drug treatment, improved sanitation
and health education.
Soil-transmitted helminth (STH) infections are considered to be an enduring public
health problem in Indonesia, although national-level data are not complete.
Available national data consist of those collected during periodic school surveys
(conducted in 8 provinces per year), the historical data collected during surveys conducted
in the last 10 years and available in literature and a complete review of the literature
conducted by the London School of Hygiene and Tropical Medicine (LSHTM) for UNICEF
Dr S. Brooker and Dr. R. Pullan from LSHTM updated the 2002 revision with more recent
data12,13 and produced the following map providing a visual localization of the available data
and their level of endemicity (Figure 7a).Figure 7a. Maps of STH prevalence in Indonesia: a. Data-based
Based on this epidemiological data and on climatic and population information the same
group in LSHTM extrapolated a map in which the areas that have a strong possibility to
have a prevalence of STH over 20% are marked in purple (Figure 7b).
11 Brooker S.(2002) Human helminth infections in Indonesia, East Timor and the Philippines. UNICEF
12 Albright JW, Hidayati NR, Basaric-Keys J. Behavioral and hygienic characteristics of primary schoolchildren which can be modified to reduce
the prevalence of geohelminth infections: a study in central Java, Indonesia. Southeast Asian J Trop Med Public Health. 2005 May;36(3):629-40.
13 Albright JW, Basaric-Keys J. Instruction in behavior modification can significantly alter soil-transmitted helminth (STH) re-infection following
therapeutic de-worming. Southeast Asian J Trop Med Public Health. 2006 Jan;37(1):48-57.Figure 7b. Maps of STH prevalence in Indonesia: b. Predicted Figure 7a. Maps of STH prevalence in Indonesia: b. Predicted
According this extrapolation, the population in need to be treated is presented in Acco
(details , the po
table: (details based on the province positives for LF and STH and province population according
population according the 2010 census data are available in the annex
the 2010 census data are available in the annex) Table 2 Population living in STH endemic areas

Total Population (2010 Census)
Total population living in STH endemic areas
Pre-school children living in STH endemic areas
School-age children living in STH endemic areas
Pre-school children living in STH endemic areas not 4.6 mil ion
School-age children living in STH endemic areas not 13.5 mil ion
endemic for LF Strategy and Activities The res
y and ty of STH sits Activities under the Diarrhea Sub-directorate in DG DC& EH but will relocate
to Sub-directorate LF & Schistosomiasis in 2011. At central level, there are 11 staff members
The responsibility of STH sits under the Diarrhea Sub-directorate in DG DC& EH but
working on LF, schistosomiasis and STH. At provincial and district health offices, there are no
will relocate to Sub-directorate LF & Schistosomiasis in 2011. At central level, there are
specific staff members for LF, schistosomiasis, and/or STH. Instead the Head of Health, the Head
11 staff members working on LF, schistosomiasis and STH. At provincial and district health
of Division, the Chief of Section and functional staff are responsible for communicable diseases. At p
staff e ad of Health
or LF, and functional staff al
schistosomiasis, so are
Division, the Chief of Section and functional staff are
esponsible for communicable diseases. At primary health centre level, the Head of Health
Centr date, the activities conducted by
e and functional staff also ar the
esponsible f -directorate
or contr include:
ol of all communicable diseases.
To date, the activities conducted by the Diarrhea Sub-directorate include:
Periodic school surveys (usually in 4 schools each in 8 provinces per year) Provision of MDA or selective treatment of positive cases (depending on availability of
• Periodic school surveys (usually in 4 schools each in 8 provinces per year)
resources and drugs nationally and at local level)
• Provision of MDA or selective treatment of positive cases (depending on availability
Health promotion and hygiene education
of resources and drugs nationally and at local level)
Promoting improvement in sanitation especially latrine coverage
pr g of health car
omoting toral and
sanitation ation
especially latrine coverage
Monitoring and evaluation of activities
• Training of health care workers and community
• Intersectoral and inter-program coordination
• Monitoring and evaluation of activities
On average less than 2 000 school age children were treated every year.
The STH Program conducts 4-days annual training of central and province STH workers
central and province STH workers central and province STH workers. The training focuses
on epidemiology, management program, laboratory diagnostic and treatment. In district
level training conduct 2 days annual training of district STH worker and health center.
The training focuses on epidemiology, management program, laboratory diagnostic and
treatment of STH. Whereas in health center level conduct one day training of cadres
(school teachers) that focuses on the an overview of LF and mass treatment .
In addition to the activities conducted by the DG DC & EH, other stakeholders such as
the Child Health Directorate (under the DG Community Health at MOH) have undertaken
MDA activities for STH. The Child Health Directorate encourages provincial authorities
to adopt MDA twice per year and coordinates with the Ministry of Education. Due to the
decentralization process, provinces and districts need to self-purchase drugs for the MDA
which has reduced compliance with the national program since the budget is not routinely
Other STH partners include the World Food Program (WFP)'s school feeding program
with which de-worming activities are paired. WFP highlighted two major challenges in the
deworming aspect of their campaigns: parents need to be educated before the deworming
campaign otherwise there is reluctance to participate, and, transportation of the WFP drugs
from the district to the schools has proved challenging. WFP operates in three provinces
NTT (Kupang, TTS and Belu districts), NTB (Central Lombok, West Lombock and East
Lombock districts) and East Java (Sampang). WFP conducted systematic deworming in
all schools in these districts during the period 2007- 2009. After that deworming was
interrupted. Only Sampang and TTS districts continue deworming with local resources.
Yaws (Framboesia tropica) is a chronic, contagious, non-venereal infection caused by the
spirochete Treponema pertenue. The disease is most prevalent in children <15 years old
and is usually associated with lack of personal and environmental hygiene.
Eighteen of the 33 provinces in Indonesia report cases of yaws, with five provinces
considered to have a high burden of the disease. The remaining 13 provinces that were
endemic in the past are considered to be very low burden. Based on the available data from
provinces, 33 districts, mostly in east Indonesia, are considered to be highly endemic and
43 are considered to be low endemic. Figure 8 shows the geographical areas in Indonesia
that still report cases of yaws.Figure 8: Geographic distribution of provinces reporting cases on yaws, IndonesiaSITUASI FRAMBUSIA DI INDONESIAFigure 8: Geographic distribution of provinces reporting cases on yaws, Indonesia

TAHUN 2009Total Kasus: 8309S. Sumatera (0)C Sulawesi (94)Papua (639)Jatim (20)
High burden province
Low burden province
As per MOH Report (03.08.2010)
No information available
The Yaws Eradication Program has been reporting a steady increase in number of new
prrogram has been rep
ogram reported orting
2001. The program reported 7,751 new cases from five provinces at the end of 2009 (Figure 9).
2009 (Figure 9). Of these, 7,400 cases were reported from active surveys carried out in 6
Of these, 7,400 cases were reported from active surveys carried out in 6 highly endemic districts
highly endemic districts in East Nusa Tenggara (NTT) province.
in East Nusa Tenggara (NTT) province. FiFigur gurea Yaws case ws case r reporepor ting in Indonesia, 200ting in Indonesia, 1-2009 2001-2009Fig.1 Trend in Yaws case reporting Indonesia 2001-2009
Strategy and Activities
Strategy and Activities
The Sub-directorate for Leprosy and Yaws, in which the Yaws Eradication Program is based, has 12 s
Sub-dir onal level
which is 1 staff
ogram. In Java and
program and yaws eradication
program are held by one staff, except in Papua, East Java and Central Sulawesi provinces.
The MOH strategy is designed to eradicate the disease by 2013. WHO guidelines recommend that whe
is an 5%, as is t
eradicate nesia, al
cases, household members and obvious contacts should be treated with a single injection
of long-acting benzathine penicillin.
The MOH strategy includes active case finding and treatment of cases and their contacts, mobilization of community support, capacity building of health staff for detection an 33
management of cases, and establishment of partnerships. The main operational activity is to
The MOH strategy includes active case finding and treatment of cases and their contacts,
mobilization of community support, capacity building of health staff for detection and
treat" missions at l of par
east o tnerships.
the di operational
atio n. would then be followed by sero-surveillance for eradication certification,
The Yaws Eradication Program conducts 2 days training of district and health center staff. HThe
this program i Pr
lability. staff.
ocuses on case diagnostic, case management and reporting-recording system.
enzathine p penicillin
re responsibility
sponsibility for dfior
stridistributing
the district level. However, the Indonesian supplier is not currently making the drug; therefore,
it to the district level. However, the Indonesian supplier is not currently making the drug;
the Yaws Program will have to procure it elsewhere.
therefore, the Yaws Program will have to procure it elsewhere.
erad eradication
ication in In in
ent with gl with
mendations14, low 14
itment and funand
ional activities activities
ple implementation
mentation of the e of
icat eradication
cognizin Recognizing
g this limitatio this
n, th limitation,
ated acti integrated
vities with activities
programs including leprosy and LF. The integrated strategy and activities are described further in
disease control programs including leprosy and LF. The integrated strategy and activities are
latter sections of this document.
described further in latter sections of this document.
appingpping of NTDs endemicity of NTDs endemicity
complete lis listing
schi schistosomiasis
stosomiasis was was
rector ectorates
OH. It i MOH.
that STH is e that
A summ varies.
LF and STH can be seen in
seen in Table 3.
Table 3: At-risk population for diseases that need mass drug distribution (LF, SCH and STH)

Population 5-12 years (school-aged children) Total population 237.3 million 45.1 million
LF endemic/ STH endemic/SCH endemic
LF endemic/ STH endemic
LF not endemic/ STH endemic
( 70.6 million)
Total in need of treatment 124.9 million 37.1 million LF not endemic/ STH not endemic Health, hygiene & nutrition promotionHealth, hygiene & nutrition promotion
iving a cl "Living
a. Indonesia.
The activiti The
es for activities
each. Fo education
for ea activities
raphi or each school under their geogra
phic purview.
ealth In Indicator
are Jogjakarta (58.2%), Bali (51.7%), East Kalimantan (49.8%), Central Java (47%) and North
14 Yaws Goals, Objectives & Strategy (WHO, 2006). www.searo.who.int/en/Section10/Section2134_10840.htm
Yaws Goals, Objectives & Strategy (WHO, 2006).
than 38.7% are Jogjakarta (58.2%), Bali (51.7%), East Kalimantan (49.8%), Central Java (47%)
and North Sulawesi (46.9%). Provinces with low performance scores are Papua (24.4%),
East Nusa Tenggara (26.8%), Gorontalo (27.8%), Riau (28.1%) and West Sumatera (28.2%).
The Riskesdas 2007 also assessed hygienic behavior, measured by appropriateness of
defecation practices (at minimum, use of latrine) and appropriateness of hand-washing
practices (wash hands with soap before eating, before handling food, after defecation, after
cleaning children's defecation and after handing animals). The survey found that 71.1% of
population ≥10 years surveyed practiced appropriate defecation practices, but that only
23.2% had good hand hygiene. The province with best hygiene practices was Jakarta: 98.6%
for defecation practices and 44.7% for hand hygiene. Provinces with low performance for
defecation practices were West Sulawesi (57.4%), Gorontalo (59.2%) and West Sumatera
(59.3%). Provinces found to have low hand-hygiene practices were West Sumatera (8.4%),
North Sumatera (14.5%) and Riau (14.6%).
Recent activities by the MOH Child Health Directorate and supported by WHO included
developing a teaching guide for teachers in primary schools about child health, development,
hygiene and nutrition. The book was finalized in 2010 and is awaiting the endorsement of
the Ministry of Education before it can be circulated to schools nationwide. This will soon
be followed by a similar book for high school students.
Integrated vector management
In Indonesia there are 23 species of mosquitoes from 5 genera found as filariasis vectors.
These are Mansonia, Anopheles, Culex, Aedes and Armigeres.
Figure 10
Species of Anopheles are the main vectors of nocturnal periodic W. bancrofti in rural areas.
The main vector of nocturnal periodic W. Bancorfti in urban areas is Culex quinquefasciatus,
a highly anthropophilic species which feeds readily both indoors and outdoors and has its
peak biting period between midnight and 3 am. The main vector of diurnal subperiodic W.
Bancrofti is the day-biting, exophilic Ae. Polynensiensis. It breeds in small water containers
and has a peak of feeding just before sunset. Mansonia uniformis is one of the main vectors
of nocturnal periodic Bancroftian and Brugian Filariasis.
Malaria is another mosquito-borne disease that plagues much of the population in
lymphatic filariasis endemic areas and is spread by Anopheles mosquitoes. In Indonesia, it is
concentrated on the outer islands of Papua, Maluku, Nusa Tenggara, Sulawesi, Kalimantan,
and Sumatra. A primary control strategy is the use of long-lasting impregnated nets (LLINs)
to reduce the number of indoor-resting mosquitoes and shift mosquito feeding from
humans to animals.
With funding from the Global Fund for AIDS, Tuberculosis, and Malaria, UNICEF and the
International Red Cross, the National Program for Malaria Control in Indonesia delivers
LLINs through either:
• Routine distributions in which every pregnant women receives 1 LLIN in the prenatal
services (immunization and maternal and child health program, midwifes, malaria post).
From 2007 to 2009, over 2.2 million LLINs were delivered according to the Malaria
World Report 2010.
• Campaigns which distribute two LLINs per family in areas at risk. The number of bed
nets distributed under this strategy is unknown.
Malaria program educational materials in Indonesia include messages about the benefits
of using LLINs for decreasing both malaria and LF transmission. During LLIN distribution
and MDA campaigns the use of LLINs should be encouraged, as advocacy for bednet use
will benefit malaria and LF control. Malaria and LF programs should strengthen their links
and send integrated messages related to vector control and protection during the routine
and campaign distribution of LLINs and during MDA campaigns. Integration between disease control initiatives
Disease control integration has taken place between the various programs within the
MOH structure, as well as through integration with various partner agencies such as World
Food Program, Ministry of Education and Ministry of Religious Affairs.
Within the MOH structure, NTD integrated control received some attention in the last
few years. In 2007, the MOH prepared Integration Guideline for the Control of LF, leprosy,
yaws and STH. The basic concept is demonstrated diagrammatically, where the various Sub-
directorates under DG DC & EH work with other units of the MOH and jointly enable the
integration of activities at the provincial and district level (including monitoring, supervision,
case detection, case management etc) (Figure 10). Schistosomiasis is not included in the
list of the diseases in this guideline since the public health problem is limited to a small
geographical area and population.
The integrated guideline outlines the principles of integration, the objectives, the strategy,
the structural organization, and the roles and responsibilities of different levels of the health
system. Importantly, the guideline recognizes that there are some activities that have the
potential for integration but that there are those that have to stand alone. The guideline
describes the mechanisms for integrating rapid mapping, endemicity surveys, health care
worker training, health volunteer training, MDA campaigns, self-care groups for case
management, health promotion activities, documentation and reporting, and monitoring
and evaluation. The guideline includes the forms that can be used by health care workers
at each level (PHO, DHO, PHC and cadres), but it does not provide scripts (step-by-step
instructions) for how each activity such as the integration of LF MDA registration with
osy suspect case finding will be conducted. Such operational guidelines are needed to
simplify the concepts, enable rapid training of health care workers and assist in standardizing
processes and activities.
operational guidelines a re needed to simplify the concepts, enable rapid training of health care
workers and assist in standardizing processes and activities.
Figure 11: Coordination between different units in MOH to enable integration of NTD contr e 10: Coordination betwol activities at local le eel different units in MOH to enable integration of NTD control activities at local level
health & Nutrition
health & Nutrition
Integrated
Since 2007, there has been limited uptake by provinces and districts of the integrated
n limited uptake of
the integrated and
nce of limite especiall
in the allocated
process for integration, especially due to the vertical budget lines allocated to each disease
to each disease control program. Nevertheless, the MOH undertook a pilot project in
control program. Nevertheless, the MOH undertook a pilot project in 2007 in two locations:
2007 in two locations: Subang in West Java to integrate leprosy and LF, and Buton in East
Subang in West Java to integrate leprosy and LF, and Buton in East Sulawesi to integrate leprosy,
the pilot wer these
areas, availability of
staff availability
on makers. staff
als showed tdecision
ents of all di for
care gr commitment
to the activities of the self-care
In addition to integration within the MOH, activities have been integrated with other programs at
example is within
on of dactivities
aigns integrated
activi combination
ty is conducte of
mary heal campaigns
district classes
level. In 1-3.
ion, in activity
Indonesia where WFP provides supplemental feeding, deworming activities including MDA twice per year, latrine provision and water provision have been integrated. The WFP no longer suppo 37
the STH control campaign but has seen sustainable local government continuation of the program in two of the seven districts.
primary health care workers who are also in charge of the UKS at sub-district level. In
addition, in the seven districts in east Indonesia where WFP provides supplemental feeding,
deworming activities including MDA twice per year, latrine provision and water provision
have been integrated. The WFP no longer supports the STH control campaign but has seen
sustainable local government continuation of the program in two of the seven districts.
Drug supply and logisticsAdequate
and timely supplies of drugs constitute a barrier to success for most of the NTD
programs. However, drug donation programs now exist for all 5 of the NTDs in the PoA,
• In 2010, Johnson & Johnson announced the donation of 200 million tablets of
Drmebendazole
ug supply and l for
ogisti countries
heavily burdened by STH. This donation program is
Adequate an y the NGO Childr
d timely supplies of en
rugs constiWorms (CWW).
tute a barrier to success for most of the NTD
programs. However, drug donation programs now exist for all 5 of the NTDs in the PoA, as
• In 2010, Eisai Co., Ltd. announced a donation of DEC for LF endemic countries. This is
still in the negotiation phases, but WHO will facilitate the donation starting in 2012.
In 2010, Johnson & Johnson announced the donation of 200 million tablets of
• GlaxoSmithKline
coun talbendazole
ries heavily b fr
program is managed thr
thout Wo .rms (CWW).
2010, Ei praziquantel
sai Co., Ltd. an nfor
ou nschistosomiasis
ced a donation of contr
in the negotiation phases, but WHO will facilitate the donation starting in 2012.
countries. This program is managed by WHO.
GlaxoSmithKline provides albendazole free of charge for LF elimination programs. This
by Novartis. This program is managed by
Merck donates praziquantel for schistosomiasis control in Africa and other selected
penicillin for some endemic
tidrug therapy for leprosy is donated by Novartis. This program is managed by WHO.
WHO supports the procurement of benzathine penicil in for some endemic countries.
Albendazole and multidrug therapy for leprosy have previously been donated to Indonesia.
prosy h ya. v eDEC
drugs are fully registered in the country. DEC is produced and procured locally. Mebendazole is
Mebendazole is registered as Vermox produced by Janssen – Cilag, which is a division of
registered as Vermox produced by Janssen – Cilag, which is a division of Johnson & Johnson in
Johnson & Johnson in Indonesia. Benzathine penicillin was produced locally but production
Indonesia. Benzathine penicillin was produced locally but production has been discontinued in
has been discontin
ued in 2010.
Within Indonesia, the MOH's DG for Pharmacy & Health Supplies procures a range of
& He quantities
201 04., the drug quantities procured through the MOH system can be seen
in Table 4. Table 4: Number of tablets procured by MOH for distribution to district level, 2010NTD Tablet/box procured
Blister pack combinations
Benzathine penicillin
The process of procurement commences each year in January, where the DG Pharmacy & Health
38Supplies compiles and agrees with pharmaceutical companies on the list of generic drugs & prices
for purchase. A ministerial decree is then signed listing the drugs and the agreed MOH purchase price. The price of the drug is adjusted for four regions in Indonesia based on the geographic distance from Jakarta. Regions and the price adjustment can be seen in Table 5.
The process of procurement commences each year in January, where the DG Pharmacy
& Health Supplies compiles and agrees with pharmaceutical companies on the list of generic
drugs & prices for purchase. A ministerial decree is then signed listing the drugs and the
agreed MOH purchase price. The price of the drug is adjusted for four regions in Indonesia
based on the geographic distance from Jakarta. Regions and the price adjustment can be
seen in Table 5.

Table 5: Drug price adjustment based on regionsRegion Provinces Price Adjustment
Jakarta, West Java, Central Java, Jogjakarta, East nil Java, Bali, Lampung, Banten
North Sumatera, West Sumatera, Riau, Jambi, 5% South Sumatera, Bengkulu, Riau Islands, Bangka Belitung, NTB
NAD, West Kalimantan, Central Kalimantan, 10% South Kalimantan, East Kalimantan, North Sulawesi, Central Sulawesi, South-East Sulawesi, South Sulawesi, West Sulawesi, Gorontalo
NTT, Maluku, North Maluku, Papua, West Papua
The ministerial decree is then circulated to each disease control program so that they can make
The ministerial decree is then circulated to each disease control program so that they can
requests for drug purchase based on their available budget and needs. These requests are
make requests for drug purchase based on their available budget and needs. These requests
submitted by April of each year. Following this, the MOH DG Pharmacy & Health Supplies
submitted by tender
Supplies ible to deliver
The elivery of dr
er the drugs to district level. Delivery of drugs commences after
April and may take until the end of the year.
Most drugs are purchased from the three state-owned companies producing generic products:
Most drugs are purchased from the three state-owned companies producing generic
PT Phapros (ceased but may in future years recommence production of benzathine
oducts: enicillin)
• PT Phapros (ceased but may in future years recommence production of benzathine
PT Indo Farma (produces mebendazole)
Farma ailable for drug donations to MOH. The first option is to establish a Special
Indo e (SAS).
oduces an agreement b
mebendazole) etween MOH and the donating agency that is
valid for one year to enable drug importation. This is especially useful for drugs that are not registered in the country. Another option is to register the drug in Indonesia; a process that takes
A separate system is available for drug donations to MOH. The first option is to establish
6-12 months. The registration is valid for five years.
a Special Access Scheme (SAS). The SAS is an agreement between MOH and the donating
agency that is valid for one year to enable drug importation. This is especially useful for
drugs that are not registered in the country. Another option is to register the drug in
Indonesia; a process that takes 6-12 months. The registration is valid for five years.
Development of Plan
RationaleEven though each Disease Control Sub-directorate at the MOH DG CDC & EH has
its own plan including some level of integrated activities for different diseases, this
Plan of Action was needed in light of:
• Recent announcement of enhanced drug donations for NTD by pharmaceutical
companies globally.
• Renewed donor interest in funding NTD activities for accelerating elimination and
• Review and evaluation of schistosomiasis program in Central Sulawesi (October-
• Finalization of LF plan for 2010-2014 (May 2010)• Need to revitalize MOH 2007 integrated disease control strategy that integrates
some activities in the LF, leprosy, yaws and STH program.
• Need to leverage resources already made available to certain NTD for the purpose
of supporting and enriching other NTD programs receiving little attention.
• Achievement of MDG goals• Decentralization of health services
• Single document with key activities about a number of NTDs in Indonesia• Illuminate synergies between NTD programs that enhance cost-effectiveness• Refine activities for accelerated control of NTDs in light of recent international
and national developments
• Promote external funding for activities
• Wider consultation in developing Plan of Action: limited to current partners but
little involvement from other sectors of government (Dalam Negeri, Bappenas).
• The large size of the country and the considerable population at risk will require a
progressive scaling up of the control activities, but the entiere area endemic fore LF
should be covered by 2015 in order to get the target of LF elimination by 2020
• The east part of the country include very remote areas with major logistic
difficulties for covering the population at risk
Plan of Action for
Plan of Action for NTD Control
i) to strengthen the Indonesian health system through improved training, advocacy and
General coor
dination at all le
vels of the health system,
then the Indonesian h collaboration
ealth system thro within
trainin gMinistr
coo y of Internal
rdination at all l Affairs and Ministr
evels of the health systey of Religious
Affairs among others, and
to strengthen multi-sectorial collaboration within the MOH, Ministry of Education
nistry of In the
, and international
i i) cooperation
to strength funding
capacity fo , r WHO
anageminternational
ent of internatiagencies)
cooperation funding (USAID, AusAID, WHO and other international agencies) and
drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel,
drugs donations (DEC, albendazole, mebendazole, benzathine penicillin, praziquantel,
leprosy ultidrug combination).
multidrug combination).
Table 6: Main goals and targets by disease Frequency of Goal Diseb sj ectives D rugs Drug InPopulation population
combination finding and
ar eas below comb
finding and applicable
(excluding <2
- To interrupt DEC + ALB
Once a year Entire
hea-l t hT o cover at
2020 risk population - To c
as public health
- To eliminate PZQ
To eliminate yaws
Once or twice School-aged
is 20% or higher.
coverage for 5 years
Frequency of Goal Disease Objectives Intervention Intervention Population Implementation
combination finding and
hyperendemic areas below 1 per 1000 population
disability due to leprosy below 35%
(excluding <2
least 65% of at-risk population with MDA by 2016
as public health
of the total at-risk population with MDA
2013a te BenzathiPneen icillActi
year All cases Vi
Frequency of Goal Disea yse aws by 2013Objec tive Ps enicillin DrufignPopulation
- To achieve a ALB or MEB MDA
combination finding and
year-s To interrupt
MDA=mass drug admintis
and achieve SAC=school-age children
(excluding <2
MEB=mebendazole elimination of
egy towards control of STH and elimination of leprosy, LF,
somiasis and yaws
2020 in Indonesia, the PoA will achieve the following expected results (ER):
establish an Updated st
integrated rategies
elimination of leprosy, LF,
Accurate estimation of the burden of these 5 NTDs
schistosomiasis and
DA by Indonesia, the PoA will achieve the following expected results
2016 ccessful management of drug donations
Strengthened capacity of health workers and volunteers
Integrated social mobilization
Updated strategies based on international guidelines and best practices
Integrated and improved MDA for LF, schistosomiasis, and STH including
Accurate estimation of the bur
as public health
den of these 5 NTDs 4 yrs
scaling up and increasing coverage
Successful management of drug donations
Integrated and intensified morbidity case detection for leprosy, LF, and
75% ugh MDA campaign
pacity of health w s an
ers and v ts of health
olunteers care workers
Integrated social mobilization
ER VIII risk In
ation and intensified case management for leprosy, LF, and yaws
Integrated and improved MDA for LF, schistosomiasis, and STH including scaling up
h field visits of the health workers and self-care groups
and increasing coverage
Strengthened monitoring and evaluation system for the 5 NTDs
To eliminate yaws
Integrated ablish
and ment of a sur
intensified veillance sy
case o r leprosy, L
detectionF , f schi
osy, s, LF, and yaws
car e workers (contact case
STH 'Suppor- tin
a results
Once or twice School-aged
ER VIII Integrated
rage o fintensified
case management f
ildren yaws through field
Creation of a National NTD Taskforce joining all stakeholders including
visits of the health w erna
ork tional actors
ers and self-care groups
Increased visibility, advoca
engthened monitoring and e cy and political comm
valuation system f itment for NTD co
or the 5 NTDs ntrol
e surveillance system for leprosy, LF, schistosomiasis, and yaws
ER XIII is In
d advocacy for comprehensive NTD control linking water,
after their elimination as public health problems
her. itation, hygiene education and chemotherapy
main grated heal
‘Supporting' expected results
s a National NTD Taskforce joining all stakeholders including national
and international actors
Increased visibility, advocacy and political commitment for NTD control and
ER XIII Increased advocacy for comprehensive NTD control linking water, sanitation,
hygiene education and chemotherapy
ER XIV Integrated health promotion
To achieve these 14 expected results the PoA will implement the following operational
ER I Updated strategies based on international guidelines and best practicesIn 2011 WHO will be publishing updated guidelines for implementation of STH control programs and monitoring and evaluation of LF programs. In light of this, as well as the revised integrated NTD strategy spelled out in this PoA, the following priority activities are recommended:
1. Creation of new national STH strategy. The MOH will develop an updated strategy
for the control of STH, based on predicted prevalence mapping and international guidelines. This strategy will include MDA through schools in areas without LF MDA, instead of the current practice of testing and treating. It will aim to harmonize STH MDA activities currently being implemented by various partners, including the Ministry of Education and World Food Programme.
2. Creation of a new LF monitoring and evaluation strategy. The MOH will develop an
updated strategy for monitoring and evaluating LF programs, based on the new WHO
guidelines to be published in 2011. This strategy will include revisions to sentinel site monitoring, assessing transmission after five effective rounds of MDA, and post-MDA surveillance. ER II Accurate estimation of the burden of the 5 NTDsThere is a significant amount of information on the burden and geographical distribution of
the 5 NTDs; however, there are still some gaps that need to be filled. Geographical mapping
is necessary to assess existing situation more accurately and develop macro and micro
planning.1. LF mapping gaps. 135 districts (total population: 102.8 million) have been classified as non-
• A 2009 WHO expert visit confirmed that 66 districts were non-endemic, given that a
large number of people were tested without finding any positive results.
• However additional districts were classified as non-endemic because they were
surrounded by non-endemic districts or because no cases of hydrocele of elephantiasis
were declared. For these districts, additional efforts should be made to ensure there is
appropriate evidence to classify the district as non-endemic prior to the development
of the verification dossier. The MOH will collect information on the methodology
used to map each district for review by the Regional Programme Review Group in
March 2011 to seek advice on whether these districts should be remapped according
to WHO guidelines.
2. STH mapping gaps. STH are known to be widespread in Indonesia, but little information is
available at central level on district-level prevalence and intensity. To rectify this problem,
the following activities will be implemented:
• The epidemiological information presented in the prediction map at page 22 is sufficient
to start control activities.
• The periodical collection of epidemiological data in sentinel sites will allow to refine
the data and to progressively adjust the control activities
3. Schistosomiasis mapping. Given that a new focus of transmission was recently detected in
the Bada valley, there is concern that schistosomiasis is more widespread than currently thought. The MOH will implement surveys in the highlands of Central Sulawesi, which
have similar ecological features as the infected areas and have migration from the infected areas, to clearly define the endemic areas.
4. NTD overlap mapping. The information available for leprosy, LF, schistosomiasis, STH, and
yaws will be compiled into maps. Those maps will help to advocate for the integrated PoA for NTDs and the planning of the diff
erent activities.
ER III Successful mana
which have similgement of drug donations
ar ecological features as the infected areas and have migration from the
Without successful
ed areas, to clearly d of
e the en donations,
the cost of the NTD Program would
ping. T individual
he information disease
leprosy, LF, could
H, asuccess.
following activities
compiled in national
cate for the drug
PoA for NTDs and the planning of the different activities.
well as distribute drugs throughout the country.
ER III Successful management of drug donations
m w Schistosomiasis,
and anpplication
one of the in fdor
disease prog mebendazole
rams could achiev do
and man(CWW).
age drug d o nThis
ations, donation
as well as could be
distribute drugs throughout the country.
deliv ered to the School Immunization program (BIAS) and distribution could be integrated
force, specif distribution
ically the Sub-di with
rectorat minimal
and Schisto transpor
somiasis, wil tation
prepare an application for a potential mebendazole donation from Johnson and Johnson
ren accomplished
delivered drugs
provided to the National disease contr
School Immunization program (BIAS) aol pr
nd disogram.
tribution could be integrated with the
vaccines distribution with minimal additional transportation cost. A list of what needs to
apply for CWWf or
gram. r eporting to donors. Table 7 shows the current estimate
of drugs needed f
2. The NTD or the next 5 y
Taskforce will be respo ears.
nsible for the annual forecasting of the drugs, calculation
of coverage and reporting to donors. Table 7 shows the current estimate
le 7.h e nexAnn t 5 years. ual drug forecastingTotal number of people to be treated Table 7. AnnuaNumber of g rug forecasting tablets per Total numb2e20p1l2e to b2e13 r eatedNumber of Atablets per
* Total amounts of drugs needed were calculated by multiplying the population at risk by number of rounds
nts of drugs needed were calculated by multiplying the population at risk by number of rounds
TaTable 8. Calculation of requirementsble 8. Calculation of requirements Calculation of requirement
Albendazole (400mg)
Multiply total population targeted
by 1.1 (adding 10% reserve)
Multiply total population targeted
by 5.5 (adding 10% reserve)
Multiply total population targeted
by 2.75 (adding 10% reserve)
It is likely that the Government of Indonesia will need to continue procuring some
supplies of DEC locally, as the potential global donation might not be sufficient.
3. Develop guidelines for managing and referring severe adverse events (SAEs). The MOH
should update their guidelines for managing and referring SAEs, following the WHO
guidelines15, developing integrated guidelines and training materials where appropriate.
Training on these guidelines should be done at provincial and district levels as part of
preparation for MDA and/or active case finding and treatment.
4. The NTD Taskforce, in collaboration with BINA, will develop a plan for strengthening
drug procurement (including drug donation applications) and supply logistics. This plan
should include the following for all 5 disease programs: • Who will be responsible for costs of customs clearance, demurrage, storage, and
transport within Indonesia.
• Opportunities for integration, particularly for transporting drugs for disease-
specific MDA and/or treatment to districts at the same time.
• Timeline of needed to ensure drugs reach district level at appropriate time. ER IV Strengthened capacity of health workers and volunteers
In order to improve the capacity of the health system to implement MDA, case finding
and management, and disability prevention, priority activities include integrated training of
health workers at all levels of the health system. 1. The national NTD Program will develop integrated training materials that will be based
on the revised strategies for LF and STH. Training materials will be based on a module
system so that they can be tailored to the diseases that are endemic at the provincial
or district level.
2. The national NTD Program will train different workers at the province level, following
the methodology of Training of Trainers. These provincial-level workers then will train
the health workers and volunteers at district and community levels to improve their
skills and knowledge.a) Central level. National sub-directorate for Filariasis and Schistosomiasis staff will
receive specific training for implementation of program-specific updated strategies
and guidelines, as well as the integrated approach.
b) Provincial level. c) District level. Health care center (Puskesmas). Depending on what diseases are
endemic at the provincial or district level, at least one health worker at every
health care center will be trained in a two-day course to undertake the following:
• MDA at population or school level
• Case finding and management for leprosy
• Case detection and management for yaws
• Case detection and management for elephantiasis and hydrocele
• Training of trainers to create self care groups at community level
• Contacts study to identify new leprosy and yaws cases at community level
• Monitoring and evaluation (form filling and collating)
15 WHO 2005. Preventive Chemotherapy for Human Helminthiasis.
d) Village level. In districts where LF MDA has already started volunteers have been
trained for the conduction of MDA. In leprosy and yaws endemic areas, every
village has at least one volunteer who has been trained for leprosy and yaws
detection. The program will integrate these volunteers and will conduct annual
one-day training for them with the following objectives:
• Case detection of leprosy patients• Case detection of yaws patients• Case detection of LF morbidity (elephantiasis and hydrocele)• Declare the detection of new cases for leprosy, yaws and LF (elephantiasis or
hydrocele). The volunteers will be trained on the use of forms to inform the health center.
• MDA: Schoolteachers and community volunteers can be recruited to deliver
these medicines to many people who are beyond the reach of the peripheral health-care system.
• Register important data for every person receiving the drugs. This data
will serve for important statistical analysis such as coverage, demographic distribution of the population attending the MDA, etc. Volunteers will be trained on how to fill the different forms
• Community mobilization prior to MDA campaigns• Health education during MDA campaigns.• Severe adverse reaction detection and declaration to the health center using
adequate forms.
• Community care of chronic patients: Providing instruction to people on how
to care for relatives or others in their community suffering from disabling morbidity from leprosy and lymphatic filariasis strengthens health systems, thereby achieving delivery and equitable access. ER V Integrated social mobilization
Social mobilization is imperative to ensure community compliance in accepting MDAs
and should increase the motivation of the at-risk individual to accept treatment as
well as on the health-care provider or community volunteer adequately informing and
motivating the community. Social mobilization is a complex process – the programme,
health-care delivery services, health-care providers and strategies for mobilization and
communication, interact to influence and provide the acceptance of the programme(s) to
local communities. 1. The Sub-directorates will work closely with the Health Promotion Department in the
MOH to produce integrated IEC materials and tools used for social mobilization.
2. The NTD Program will seek the participation of all possible inter-sectoral partners
and allies in strategically selected communication interventions to develop organized
ER VI Integrated and improved MDA for LF, schistosomiasis, and STH This section includes activities to scale up and increase coverage in MDA campaigns to
achieve the goals for control of STH and elimination of LF and schistosomiasis. MDA
campaigns will be used as an opportunity to deliver drugs, detect new cases (leprosy, LF,
and yaws), and promote hygiene (which will benefit all 5 NTDs programs).
1. MDA in LF-endemic areas will be planned using the following recommendations:
• Implementation unit (IU) will be the district.• When contiguous districts have less than 1 million people each, they can form
groups with other contiguous districts, if the total population of each group is
no more than 1 million people. These groups can serve as Evaluation Units (EU)
for assessing the impact of MDA.
• In districts where the population is higher than 1 million, they should be divided
by sub-districts into separate IUs of less than 1 million each.
• All communities within the same IU or EU will start MDA the same year.• To count as an ‘effective' MDA, each IU or EU should achieve coverage of at
least 65% of the total at-risk population in any annual round.
• MDA campaigns will follow the principle of directly observed treatment, i.e.
each eligible person has to ingest the drug in front of the drug distributor.Figure 11. Algorithm for integrated MDA

Figure 12. Algorithm for integrated MDADistricts wher e LF is endemic:
• Schistosomiasis
Districts non-endemic where LF is ende arc: : One annual LF MDA round will distribute
DEC+ALB to the entir
endemic areas: childr
stribute DEC+ALB to
the entire population (excluding children under 2 years old, pregnant women, and
women, and severely ill).
• Schistosomiasis
c areas: Si (Lindu
gi Distri subdistrict),
ct (Lindu subd iPoso
strict), district
Utara, Lore Timur
re P Subdistricts)
iore Subdistri (see
ee annex for
full li list
endemic vil ages) will
villages) will receiv
same logi logistic
echanism. The fir The
MDA will distribute DEC+Albendazole to the entire population (excluding children under
first round of LF
ld, p rdistribute
en and severely ill).
round will distribute
(excluding children
years. It will be
nducted six Praziquantel(without
months after the first roun albendazole??)
older than 4 years. It will be conducted six months after the first round.Districts where LF is not endemic:Districts where LF is not endemic:
STH <20%: (DKI Jakarta, Jawa Tengah) No MDA will be conducted in those areas. MEB or
• STH <20%: (DKI Jakar
th care conducted
center for indin
or ALB should be a
STHvailable in e
ces) One ann e center f
ual round or individual tr
of MEB (or ALB) eatment.
will be co nducted. Target
population will be school age children (5-14 years), both enrolled and non-enrolled.
• STH >20%: (7 pro
coul conducted.
population will be
erage and olled.
There are two possible pr
progra ograms with which STH MD
m it is the preferred mechanism tA could be integrated:
o reach school-age children. The program
implements an annual round for TT and DT immunization in November. Teachers are
School immunization
or distri (BIAS):
this program it is
. STH drugs c to
be de school-age
livered to the childr
program implements
courag .e d to visit
Teachers are trained
ols odistribution
n the days of of
vision of health
workers fr om the immunization team. STH drugs could be delivered to the BIAS
and distributed with the vaccines to the schools. Non-enrolled children would be
encouraged to visit schools on the da
ys of the campaign to receive MDA.
School Health Program (UKS). Linking deworming with activities conducted by
health workers in schools. ER VII Integrated and intensified morbidity case detection
Case detection for leprosy, LF, and yaws will be integrated and intensified through MDA
campaigns and field visits of health care workers (contact case detection). As leprosy or
yaws case-detection rates decrease, the average cost of detecting a case increases. Many leprosy control programmes now rely on voluntary case-finding supported by IEC activities
to raise and maintain awareness of the early signs and symptoms of leprosy. However integrating case detection with MDA campaigns will have the benefit of increasing case finding without having to support the entire cost of the campaign.
1. In areas where LF is endemic, MDA annual campaigns will be used to detect new
cases of leprosy and yaws.• IEC and communication materials will inform the population of the main signs and
symptoms for all 5 NTDs, with an emphasis on leprosy, LF, and yaws.
• Suspected cases will be encouraged to present to trained volunteers during the
• Trained volunteers will consult suspected cases during the MDA and notify them
to the health center.
• Suspected case will be encouraged to visit the health center to confirm diagnosis
and receive adequate treatment and advice.
2. After the MDA, forms declaring suspicious cases will be sent to the health care
• Trained health workers will receive the forms and will plan field visits to consult
every suspicious case and confirm diagnosis.
• Contacts leaving in same community as index cases will be tested to detect new
cases of yaws and leprosy in early stages of the diseases.
ER VIII Integrated and intensified case managementCase management will be integrated and intensified for leprosy, LF, and yaws through field
visits of the health workers and establishment of self-care groups.
1. Health workers will conduct field visits to every area where new cases of leprosy
and yaws are suspected.
2. Patients will receive adequate treatment for leprosy and yaws.3. Where a number of people suffering from leprosy and LF morbidity live in the same
district and at an adequate distance (for instance, 5 kilometers) a self-care group will
be established.• People living with leprosy and LF chronic disabilities will be invited to participate
in their nearby self-care group. The patients will be informed about the benefits of joining the self-care group, including: learning improved management of their
disabilities, preventing and reducing disabilities, improving treatment and care
compliance, and fighting stigma and discrimination in the community. ER IX Strengthened monitoring and evaluation (M&E) system for the 5 NTDs
To monitor and evaluate the achievements of the NTD Program, three main categories
of indicators can be used (Figure 12).Figure 13. Categories of indicators for monitoring preventive chemotherapy
A: Process indicators
B: Performance indicators
C: Impact indicators
Prevelance/intensity of infection
Process and performance monitoring will be carried out to assess the efficiency of program
implementers, treatment coverage by drug distributers, and to identify issues that are hindering or enhancing the program. Results will help ensure that appropriate health
education messages are being delivered and understood, and that treatment coverage is
Impact evaluation starts prior to an intervention in order to determine the burden and
geographical distribution of a disease. These results then can be compared with later years
after treatment has been implemented. In areas with overlap of LF and STH, it would be possible for the prevalence of STH to be monitored through collection of stool samples in
the STH-targeted population in the LF sentinel and spot-check sites. Cross-cutting impact indicators such as anemia and disability also could be added to sentinel site data collection
where appropriate.
Academic and research institutes, such as the National Institute for Health Research
and Development, and the University of Indonesia, will be key partners in the design and implementation of M&E for the integrated NTD Program.The following are priority activities for strengthening the M&E system:
1. The integrated NTD Program will conduct M&E in accordance with WHO guidelines,
including the following:• Monitoring drug coverage for preventive chemotherapy (2010) http://whqlibdoc.
• Monitoring and evaluation of mass drug administration in the programme to
eliminate lymphatic filariasis (draft, to be published in 2011)
• Helminth control in school age children, 2nd edition (draft, to be published in
• Leprosy Elimination Monitoring (2000) http://www.who.int/lep/monitor/LEM_
• Handbook of Endemic Treponematoses: Yaws, Endemic Syphilis, and Pinta (1984)
2. Integration of disease-specific programme M&E systems: Efforts will be made to
reduce the burden of data collection and reporting by combining reporting formats and surveys, where feasible in areas with overlap of diseases.
3. Planning for resources for M&E: As a follow-up step to the planning done as part of
this PoA, the NTD Program will forecast annual needs for M&E, including number of
districts in which surveys will take place, number and type of diagnostic tests needed,
and technical assistance needed. Included in this document will be annual forecasting of the following:
o number of districts implementing sentinel and spot-check site data collection for
o number of districts implementing transmission assessment surveys for LF,o number of districts implementing prevalence surveys for schistosomiasis,o Number of districts implementing leprosy elimination monitoring (LEM) for
ER X Establishment of a surveillance system for leprosy, LF, schistosomiasis and yaws after their elimination as public-health problems
Indonesia will prepare a surveillance mechanism that will be established once leprosy, LF,
schistosomiasis, and yaws are eliminated from the country as public health problems.Surveillance will include notification of cases from the local to the central level, keeping the
health workers on alert and in the community for early detection of any remaining cases. For LF and schistosomiasis, surveillance will include active surveillance like community
surveys, snail surveys and use of antibody tests. WHO can technically support the MoH in the development of the surveillance
ER XI Establishment of a national NTD Taskforce
The national NTD Taskforce will join all NTD stakeholders including national and
international actors. Inter-sectoral networking of stakeholders such as media, social welfare, water and sanitation supply, environment, education, will be promoted to maximize their
participation, as NTDs are diseases related to poverty and poor living conditions.
1. A NTD Taskforce will be created including representatives of the following
stakeholders:• Ministry of Health Sub-directorates: LF and SCH, Diarrheal, Malaria, Vector
Control, Child Health , Health Promotion
• Ministry of Education • Ministry of Religious Affairs
• Ministry of Internal Affairs• WHO: Malaria and Vector-borne Diseases, Nutrition, Health Promotion
• Other International agencies: UNICEF, WFP• International cooperation agencies: USAID, AusAID
2. The NTD Taskforce will have biannual meetings. The main objectives of these meetings
will be to coordinate activities, share information, discuss potential conflicts and proposed solutions, and evaluate the NTD program.
ER XII Increased visibility, advocacy and political commitment for NTD control and elimination
Advocacy will be essentially targeted to political leaders and decision makers of affected
districts and provinces to build up political commitment and mobilize resources to support
1. The NTD Taskforce will advocate to ensure commitment and participation at the
different levels, including government support and funding allocations at central and district levels.
2. The NTD Taskforce will liaise with mass media entities, such as TV, press and radio,
to encourage their involvement in the NTD Program. Attempts will be made to
obtain TV, press, and radio coverage of IEC messages and MDA campaigns at reduced or no cost.
3. Government staff at all levels will be encouraged to include religious and other
community leaders in their program implementation, specifically to aid in community
awareness raising, behavior change activities, and outreach to isolated or vulnerable
ER XIII Increased advocacy for comprehensive NTD control linking water, sanitation, hygiene education and chemotherapy
Despite the obvious health benefits that accrue from improved sanitation, the targets
set under Millennium Development Goal 7 are far from being met, especially in the African and South-East Asia regions. Until this situation improves, many NTDs and other
communicable diseases will not be eliminated, and certainly not eradicated. The development
and transmission of the NTDs reviewed in this report are related to water, sanitation and hygiene. The situation is emphasized in the flow chart in Figure 13.
Figure 14. Interconnectedness of water and sanitation and the transmission of infectious agents16.
a Source: Adapted from Pruss Aet al (9)
The WASHED framework (Figure 14) highlights how water, sanitation, hygiene education
and preventive chemotherapy are the best tools to achieve sustainable control and elimination of NTDs included under this NTD Program.
16 Working to overcome the global impact of neglected tropical diseases. WHO 2010
Figure 15. WASHED FrameworkWASHED FrameworkThe following table summarizes the components of the WASHED Framework to promotecomprehensive STH control.
• Access to portable water• Drainage and disposal/re-use/recycling of household waste water (also
referred to as "grey water")
• Access to safe and sanitary sanitation facilities• Safe collection, storage, treatment and disposal/re-use/recycling of human excreta (feces and urine)• Management/re-use/recycling of solid waste (rubbish)
Hygiene Education
• Appropriate information regarding prevention and treatment 0f STH and schistosomiasis• Dissemination of key hygiene messages to promote the following practices
- Safe water storage - Safe hand-washing and bathing practices
- Safe treatment of foodstuffs
• Regular mass drug administration
Source: Evans, B. (2005) Securing Sanitation: The Compelling Case to Address the Crisis. Stockholm International Water Institute in collaboration with WHO. (Table has been adapted to included education and dewormingcomponents.)
1. The Program will advocate at the central, province and district levels for
comprehensive control of NTDs promoting sanitation improvement, water
access and hygiene promotion together with the chemotherapy distribution. ER XIV Integrated health promotion The 5 NTDs included in the PoA are related to lack of adequate hygiene practices. Patients
suffering from chronic lymphoedema and leprosy ulcers would benefit from improved
hygienic behavior. Given this, the PoA will put in place a number of activities related with
health promotion and hygiene education.
1. Communication for behavioral change (COMBI) is a holistic planning framework
that helps to make a more effective and strategic use of the IEC materials and
activities to achieve behavioral impact. COMBI engages people to adopt suggested healthy behaviors through a strategic blend of communication actions in a variety
of settings, which are appropriate to the circumstances of the district and the community. Four actions will be taken:
• Public relations, including mass media, and meetings and discussions with local
administrative and religious leaders.
• Community mobilization, including participatory research, traditional media,
songs, shows, leaflets, posters, and home visits by volunteers.
• Sustained appropriate advertising to engage people by making them review the
merits of the recommended behavior in comparison with the cost of carrying the behavior out. The advertising has to be massive, repetitive, intense and
persistent. Diffusion via will be radio, television (cost of production of a TV
spot around 100.000USD), news papers among others.
• Interpersonal communication.
2. Identify the major challenges and the best methodology to change behavior for
the different targeted audiences during the planning of the health promotion
interventions.• Hygiene Education during the MDA campaigns: MDA campaigns offer a unique
opportunity to educate communities and promote hygiene. Banner, posters, leaflets and other IEC materials will be used to promote hygiene and to
educate people about the 5 NTDs. When possible MDA campaigns will be
organized near to clean water sources and hand washing will be promoted in the community during the MDA before ingesting the pills as an example of
good hygiene practice.
• Hygiene education during the social mobilization activities. Media will be
involved in the social mobilization activities. Information about the 5 NTDs
together with hygiene promotion will be integrated in the messages sent to the community. Key messages will include hands and body washing, foot
wearing, and care seeking when suspicious lesions appear in your body.
• Hygiene Education at the schools. Hygiene Education is already included in
school curriculum in Indonesia. Immunization and deworming integrated days
will be used to consolidate hygiene messages and hand washing promotion. Every child will be invited to wash his/her hands before taking the deworming
pills. Posters with hygiene promotion messages and pictures will be used to decorate primary school classes.
• Hygiene education at the self-care groups. Volunteers and health workers
leading self-care groups will train patients on how to improve their quality
of life and reduce the appearance of disabilities with good hygienic practices. Patients will help other members of the group to be systematic in their hygiene
and insert those practices several times a day in their daily routine.
• Hygiene and health promotion at the health care center. The NTD Taskforce
will advocate the inclusion of key messages on any contact with the health
system. Bednet distribution for malaria will include messages on LF prevention as well as malaria. Health workers will be trained to inform patients about
intestinal parasites when they promote hand washing for flu or diarrhea
prevention. Posters promoting hygiene and giving information about NTDs will be placed on health center walls.FILARIASISA. Detailed activities & TimeNO ACTIVITIES A. Accelleration Program of Filariasis Elimination, Drug Availability and
To maintain To maintain
the MDA to the MDA to the MDA to the MDA to
cover entire cover entire cover entire cover entire
population in 45
districts, and districts, and districts, and districts, and
increase the increase the increase the increase the
entire population 47.615.400
districtswith districtswith districts
106.277.359 with
administered administered people are
Socialization of
Socialization Socialization Socialization Socialization
the filariasis case of the
ofclinical cases
filariasis case filariasis case filariasis case filariasis case
community, head involving
of vil age, PKK,
vil age, PKK, vil age, PKK, vil age, PKK, vil age, PKK,
90% of filariasis
management management management management
(Penanganan (Penanganan (Penanganan (Penanganan
all SAE cases all SAE cases all SAE cases all SAE cases
treated properly and treated
standard and standard and standard and standard and
NO ACTIVITIES A. Accelleration Program of Filariasis Elimination, Drug Availability and
entire population 47.615.400
districtswith districtswith districts
106.277.359 with
integrated model integrated
of filariasis and
administered administered people are
filariasis and filariasis and filariasis and
Socialization of
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the filariasis case of the
ofclinical cases
filariasis case filariasis case filariasis case filariasis case
NTT, Papua, NTT, Papua, NTT, Papua, NTT, Papua,
West Papua. West Papua. West Papua. West Papua.
community, head involving
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vil age, PKK, vil age, PKK, vil age, PKK, vil age, PKK,
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for targeted for targeted for targeted for targeted
106.277.359 110.307.066
90% of filariasis
B. Program Manag mat, t Adv filariasis Sociali asis a rinasis ll ance
management management management management
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(Penanganan (Penanganan (Penanganan (Penanganan
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m Term t. Mediudistrict.
elimination Filariasis
Plan 2010-2014. Plan 2010-2014. Plan 2010-2014.
all SAE cases all SAE cases all SAE cases all SAE cases
treated properly and treated
standard and standard and standard and standard and
Commitment to Commitment to Commitment to Commitment to Commitment to
through policies through policies
through policies through policies through policies
financing at the
financing at the
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Plan on Filariasis Plan on Filariasis Plan on Filariasis Plan on Filariasis Plan on Filariasis
B. Program Management, Advocacy, Socialization and Surveillance
20 1 0-2014. nPee
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l MDA sectors in MDA sectors in MDA sectors in MDA sectors in MDA
nt implementation implementation implementation implementation
14. To collaborate
sector, private,
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sector, private,
linkage be wider linkage be wider linkage be wider linkage be wider linkage be wider
6 . To increase To increase
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toward the through health
elimination community and community and community and community and community and
endemic districs endemic districs 181endemic
endemic districs endemic districs
7. To conduct Baseline survey
MDA results are MDA results are MDA results are MDA results are MDA results are
received in time, received in time, received in time, received in time, received in time,
To improve skill To improve skill To improve skill To improve skill To improve skill
surveillance Episodes (SAE)
10. To develop To undertake
monitoring systematic
all administrative all administrative all administrative al administrative all administrative
11. To conduct Mid Term
prevalence after prevalence after prevalence after prevalence after prevalence after
prevelence MDA in 16
after MDA districts/municip
prevalence after prevalence after prevalence after prevalence after prevalence after
pre-certification, pre-certification, pre-certification, pre-certification, pre-certification,
7. To conduct Baseline survey
B. Program Management, Advocacy, Socialization and Surveillance nicipalities municipalities municipalities municipalities municipalities
010n-t2. 0 14. govern
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1 2. To increase To increase case To increase case To increase case To increase case To increase case
case finding finding in non
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Im appro schistosom elim Develo
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Coordina for schistosom w level routinely 2 tim year
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eetings for ST orking group at
Coordi m w cetral level routinely 2 tim Conduct coordi m w provincial level 2 tim
Conduct coordi m w district level 3 tim a year
A socialization to stakeholders at central, provincial and district level that are stated as ST order to support the cross sector im ST
ing coordination
ing coordination
eetings for ST orking group at district
dvocacy and socialization
C ST cetral level routinely 2 tim
Conduct m group at provincial level 2 tim
Conduct m w level 3 tim
A to stakeholders at central, provincial and district levels that are stated as ST order to support the cross sector im reduction
reduction
C for ST at cetral level routinely 2 tim
Conduct coordination m for ST at provincial level 2 tim
Conduct coordination m for ST group at district level 3 tim
Advocacy socialization to stakeholders at central, provincial and district levels that are stated as ST order to support the cross sector im reduction
A guideliness of ST reduction
Activites ACTIVITIES
ng group coordination orki w
TRASMITTED HELMINTHISIS
dvocacy and socialization
C procedure criteria (N
Detailed activities &
socialization ination through ination through
Pl anni trained field officer as needed
Increase ST H hea com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom electronic m
Pl trained field officer as needed
Increase ST hea com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom electronic m
otion in the otion in the m unity ponent
Planning and providing trained resources accordance w needs at the central, provincial and district
Pl anni trained field officer as needed
Increase ST H through hea prom com com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom and electronic m
Planning and providing trained resources accordance w needs at the central, provincial and district
Pl trained field officer as needed
Increase ST through hea prom com com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom and electronic m
otion in the otion in the m unity ponent
ith the needs in
Planning and providing trained staff in accordance w ith the needs in laboratory
Pl anni trained field officer as needed
Increase socialization ST H through hea prom com com
Increase socialization reduction of ST the com through hea prom
Increase socialization reduction of ST through hea prom and electronic m
Planning and providing trained staff in accordance w laboratory
Pl trained field officer as needed
Increase socialization ST through hea prom com com
Increase socialization reduction of ST the com through hea prom
Increase socialization reduction of ST through hea prom and electronic m
Pl anni trained field officer as needed
Increase socialization ST H hea com
Increase reduction of ST com through hea prom
Increase reduction of ST through hea prom electronic m
Pl trained field officer as needed
Increase socialization ST hea com
Increase reduction of ST com through hea prom
Increase reduction of ST through hea prom electronic m
and providing hum
laboratory staff
laboratory staff
otion in the unity com
Management
otion in the m unity com
Management
Planning trained resources accordance w needs of the program at the central, provincial and district
Planning and providing trained in accordance w needs in laboratory
Pl anni trained field officer as needed
Increase socialization ST H through hea prom com
Increase socialization reduction of ST the com through hea prom
Increase socialization reduction of ST through hea prom electronic m
Planning trained resources accordance w needs of the program at the central, provincial and district
Planning and providing trained in accordance w needs in laboratory
Pl trained field officer as needed
Increase socialization ST through hea prom com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom electronic m
Resources Resources ACTIVITIES
anagers training
ACTIVITIES
m anagers training m
of ficer d ofel d
Socialization to com
Socialization to com
Improving the Human
Laboratory staff training
Laboratory staff training
Improving Health Pr
Socialization to com
Improving the Human Improving Health Pr
Socialization to com
ith the ith the strict istrict
edia otion otion
about ST about ST
oordination w oordination w
aking the school aking the school
onitoring the use of onitoring the use of
onitoring the adequacy onitoring the adequacy
bservation the bservation the
Pl trained field officer as needed
Increase ST hea com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom electronic m heaC health division in the m division in the m copyngand distribution copying and distribution of reductionST of reduction ST m mater
C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum
Conduct Conduct stool survey on stool survey on elem elem students 6 D students 6 D C C finished finished
M Monitoring the use of latrine latrine
M Monitoring the adequacy f clea w of clean w
O Observation the disposal ofousehold disposal of household w waste
hea division in the m copying and distribution of reduction ST m
C Provincial and D Education O m curriculum
Conduct stool survey on elem students 6 D C finished
O disposal of household w
ith aking, aking,
ith the strict istrict
2014 2014
and providing and providing
otion in the unity
2014 prom prom
aterials as aterials as
ater ater oordination w oordination w
aking the school
aking the school
istrict / C istrict / C D D has finishedA
onitoring the use of onitoring the use of
onitoring the onitoring the
bservation the bservation the
Planning and providing trained resources accordance w needs at the central, provincial and district
Pl trained field officer as needed
Increase ST through hea prom com com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom and electronic m
heaC health division in the m division in the m copying copying distribution of distribution of reduction reduction m mater C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum
Planning Planning laboratory equipm laboratory equipm nd m and m needed needed Conduct Conduct stool survey on stool survey on elem elem students in 30 D students in 30 D / C / City w is non endem is non endem D District / C M MD
M Monitoring the use of latrine latrine
M Monitoring the adequacy adequacy wat wat O Observation the disposal ofousehold disposal of household w w
hea division in the m copying distribution of reduction m
C Provincial and D Education O m curriculum
Planning laboratory equipm and m needed
Conduct stool survey on elem students in 30 D / C is non endem D M
O disposal of household w
ith aking, aking,
ith the strict istrict
with the istrict
ffice in ffice in
2013 2013
otion in the unity
aterials as aterials as
ith the needs in
ater ater oordination oordination
aking the school
aking the school
istrict / C istrict / C D D has finishedA
onitoring the use of onitoring the use of
onitoring the onitoring the
bservation the bservation the
Planning and providing trained staff in accordance w laboratory
Pl trained field officer as needed
Increase socialization ST through hea prom com com
Increase socialization reduction of ST the com through hea prom
Increase socialization reduction of ST through hea prom and electronic m heaC health prom division in the m division in the m copying copying distribution of distribution of reduction reduction m mater C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum
Planning and Planning and laboratory equipm laboratory equipm nd m and m needed needed Conduct Conduct stool survey on stool survey on elem elem students in 30 D students in 30 D / C / City w is non endem is non endem D District / C M MD
M Monitoring the use of latrine latrine
M Monitoring the adequacy adequacy wat wat O Observation the disposal ofousehold disposal of household w w
hea division in the m copying distribution of reduction m
C Provincial and D Education O m curriculum
Planning and laboratory equipm and m needed
Conduct stool survey on elem students in 30 D / C is non endem D M
O disposal of household w
ith the ith the strict istrict
istrict / istrict /
with the istrict
about ST about ST
aterials as needed aterials as needed
here filariasis is here filariasis is
has finished. has finished.
aterials as needed
here filariasis is
oordination oordination
aking the school aking the school
istrict / C istrict / C D D has finished.A
onitoring the use of onitoring the use of
onitoring the adequacy onitoring the adequacy
bservation the disposal bservation the disposal hous hous
Pl trained field officer as needed
Increase socialization ST hea com
Increase reduction of ST com through hea prom
Increase reduction of ST through hea prom electronic m
heaC health division in the m division in the m copyngand distribution copying and distribution of reductionST of reduction ST m mater
C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum
Planning and providing Planning and providing laboratory equipm laboratory equipm nd m and m
Conduct Conduct stool survey on stool survey on elem elem students in 30 D students in 30 D C C non endem non endem D District / C M MD
M Monitoring the use of latrine latrine
M Monitoring the adequacy f clea w of clean w
O Observation the disposal of of
hea division in the m copying and distribution of reduction ST m
C Provincial and D Education O m curriculum
Planning and providing laboratory equipm and m
Conduct stool survey on elem students in 30 D C non endem D M
ith aking, aking,
ith the strict istrict
istricts istricts
edia otion otion
ffice in ffice in
about ST about ST
laboratory staff
otion in the unity com
aterials as needed aterials as needed
Management
aterials as needed
ater ater oordination w oordination w
aking the school
aking the school
bservation the bservation the
Planning trained resources accordance w needs of the program at the central, provincial and district
Planning and providing trained in accordance w needs in laboratory
Pl trained field officer as needed
Increase socialization ST through hea prom com
Increase reduction of ST the com through hea prom
Increase reduction of ST through hea prom electronic m heaC health prom division in the m division in the m copying copying distribution of distribution of reduction reduction m mater C C Provincial and D Provincial and D EducationO Education O m making the school curriculum curriculum
Planning and providing Planning and providing laboratory equipm laboratory equipm nd m and m
Conduct Conduct stool survey on stool survey on elem elem students in 15 D students in 15 D / C / City w non endem non endem
Conduct Conduct the latrine availability the latrine availability coverage coverage Conduct Conduct clean w clean w
O Observation the disposal ofousehold disposal of household w w
hea division in the m copying distribution of reduction m
C Provincial and D Education O m curriculum
Planning and providing laboratory equipm and m
Conduct stool survey on elem students in 15 D / C non endem
Conduct the latrine availability coverage
O disposal of household w
Resources Survey Survey
prevalence prevalence
ACTIVITIES
anagers training
ACTIVITIES ACTIVITIES
ental sanitation ental sanitation
ACTIVITIES
aterials at school aterials at school
aterials at school
Prevalence Prevalence Prevalence
Socialization to com
apping ST apping ST
he availability of latrine he availability of latrine
he availability of clean w
Laboratory staff training
Socialization to com
he availability of clean w
he availability of latrine
Improving the Human Improving Health Pr
Supply of laboratory m Supply of laboratory m equim equipm
Supply of laboratory m equipm
he availability of clean wT
Environmental Environmental d. d. 1. 1.
has finished as A
any as 11.497.076
any as 7.657.457
istrict / C D any as 1.926.432
Ensuring the availability of albendazole drugs as needed
M residents in filariasis endem conducting M 109.495.966 peo adm
Sel treatm elem students in filariasis endem conducting M m students
Sel treatm elem students in filariasis non endem 30 districts/C m students and in 20 D M m students
any as 11.300.674
Ensuring the availability of albendazole drugs as needed
M residents in filariasis endem conducting M 107.625.467 peo adm
Sel treatm elem students in filariasis endem conducting M m students
Sel treatm elem students in filariasis non endem districts/C as 5.596.045 students and in 30 D C finished as m 1.709.399 students
any as 10.093.122
Ensuring the availability of albendazole drugs as needed
M residents in filariasis endem conducting M 97.049.253 people adm
Sel treatm elem students in filariasis endem conducting M m students.
Sel treatm elem students in filariasis non endem districts/C as 3.169.157 students and in 22 D C finished as m 523.440 students
any as 8.493.813
Ensuring the availability of albendazole drugs as needed
M residents in filariasis endem conducting M 80,893,457 people adm
Sel treatm elem students in filariasis endem conducting M m students.
Sel treatm elem students in filariasis non endem districts/C as 1.634.803 students and in 17 D C finished as m 295.982 students
Ensuring the availability of albendazole drugs as needed
M residents in filariasis endem conducting M 64.171.092 people adm
Sel treatm elem students in filariasis endem conducting M m students.
ACTIVITIES Treatment
aticaly and aticaly and
ination STH ination STH plete and tim plete and tim
inistration level
inistration level
eports on the plem
eports on the plem
R R im im elim elim com com either from either from central level central level Conduct Conduct systim systim per per evaluation in overal evaluation in overal adm adm
plete and plete and
2014 2014
aticaly and aticaly and
ination STH ination STH
to central level to central level
ely either from C C
eports on the plem
eports on theRR im im elim elim received com received com tim tim PH PH Conduct Conduct systim systim per per and evaluation in and evaluation in overal adm overal adm level level
H H plete and plete and
aticaly and aticaly and
ination ST ination ST
to central level to central level
ely either from C C
eports on the plem
R R im im elim elim received com received com tim tim PH PH Conduct Conduct systim systim per per and evaluation in and evaluation in overal adm overal adm level level
K K successful for the successful for the im im ST ST program program plan as folow plan as folow
H H plete and plete and
aticaly and aticaly and
ination ST ination ST
ely either from ely either from
inistration level
inistration level
eports on the plem
eports on the plem
R R im im elim elim received com received com tim tim to central level to central level Conduct Conduct systim systim per per evaluation in overal evaluation in overal adm adm
H plete and plete and
2011 2011
aticaly and aticaly and
ination ST ination ST
eports on the plem
eports on the plem
R R im im elim elim received com received com tim tim to central level to central level Conduct Conduct systim systim per per and evaluation in and evaluation in overal adm overal adm level level
Program Program anagement imination anagement imination
prevalence prevalence
STH STH STH of of of of ACTIVITIES ACTIVITIES
ng ng tori torini ni
ecording and reporting ecording and reporting
Evaluation Evaluation (External required) 26,152,800 13,604,700 (External required) 26,152,800 13,604,700 et Estimation in USDation in Uperational (External required) 26,152,800 isease Budget E13,604,700 ropical DTropical Disease Budgperational (External required) 26,152,800 eglected TIntegrated N13,604,700 perational (External required) 26,152,800 Integrated Neglected 13,604,700 escription rand Total e (2011-20m ogramme (2011-2015)hic Control ProgramTransmitted Helminthic Contr for Soil Transmctivities Financing f
central Province and D
proving humStrengthening the activities
Socialization to com
0,000 5,000 0,000
,000 ,500 e (2011-20hic Control Program for Soil Transm
tion unity tion pr unity at riskctivities
er train ning m
central Province and D
proving humrand totalStrengthening the activities Prevalenc
Supply of labInterse equi
cri A Im Treatm Pro Supply of drug Labo TreaIm Recordi
M Socialization to com
Evalua Socia Evaluation of intersectoral coordination H EvalTotal Estimrequired) perational gaps Operational gaps 11-2015) ymphatic Filariasis Pr rogramme Financing fActivities
icroscopis, program
Total Estrequired) perational gaps Operational gaps rogramme Activities
overage survey (assessm
- Mee - Baseline
Soc - Prevalence survey - Social m
- Evaluation Impl
- technical assistance
Total Estrequired) perational gaps O6,000 ,000 l fun60 red)perational gaps
244,000 663rogramme Activities
puter and printer
overage survey (assessm
- Prevalence survey
- H - technical assistance
Soc - C - Social m - C - fo - Stationery D
- LC - D - Telephone - M - Printing - D GFinanc 7. or Schistosomiasis Elimination Pr
aterial and equipm
ctivities Financing f
, standard, procedure criteria
ental survey
ental sanitation
al survey (cattle, buffalo, pig and dog)
orking group coordination m
proving health promStrengthening the activities
Laboratory staff train
Prevalence survey
Supply of laboratory and m
Stool survey and clin
nnual Cosnnual Cos
aterial and equipm
aterial and equipm
ctivities ctivities
, standard, procedure criteria
, standard, procedure criteria
anagem in
tersectoral coordin
anager train anageme
ental survey
ental sanitation g the norm
ental survey
ental sanitation
ent of four year prevalence
al survey (cattle, buffalo, pig and dog)
al survey (cattle, buffalo, pig and dog)
orking group coordination m
proving health prom
ss/selective treatm
orking group coordination m
proving health prom
onitoring an ealth prom
rand total Strengthening the activities
Laboratory staff train
Prevalence survey
Supply of laboratory and m
Stool survey and clin
Rat survey Strengthening the activities Environ Polit Availa W Availa Advocacy an Environm Treatm Com
Supply of drug Im Ma Program Clin Laboratory staff train Strengthening m Fie
Supply Cadres train
Supply of data processing equipm Im Penyediaan Socia Recording and reporting Socia M H Snail control Supply Control of snail foci Prevalence survey Supply of bay Supply of laboratory and m Intensification and extensific
land Stool survey and clin
2011-2015 (2011-2015) Yaws Elimination Preprosy anctivities Financing f
Preparatory Phase:
100,000 50,000 100,000 600,000 200,000 50,000 50,000
3,500,000 2011-2015
300,000 350,000
1,500,000 1,000,000
5,000,000 (2011-2015)
30,000 20,000 10,000 20,000
40,000 50,000 20,000 20,000
90,000 300,000 50,000
1,000,000 eprosy anctivities
Preparatory Phase: - Su
- Sup - Trai Village
Sero surveill - Operati
Procurem - Stakehold

University Department of Pharmaceutical Sciences Evaluative Report of the Programme Name of the Programme: University Department of Pharmaceutical Sciences Year of establishment : Is the Department part of a School/Faculty of the university? Faculty of Science and Technology Names of programmes offered (UG, PG, M.Phil., Ph.D., Integrated Masters; Integrated Ph.D., D.Sc., D.Litt., etc.) : a. PG - M. Pharm. in six different specializations viz.,